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Physical
Examination
AND History Taking

B A T E S’ Guide to

Physical
Examination
AND History Taking

B A T E S’

T W E L F T H E D I T I O N

Guide to

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

G u e s t E d i t o r

Richard M. Hoffman, MD, MPH, FACP

Professor of Internal Medicine and Epidemiology
Director, Division of General Internal Medicine
University of Iowa Carver College of Medicine
Iowa City, Iowa

Acquisitions Editor: Crystal Taylor
Product Development Editor: Greg Nicholl
Marketing Manager: Michael McMahon
Production Project Manager: Cynthia Rudy
Design Coordinator: Holly McLaughlin
Art Director: Jennifer Clements
Illustrator: Body Scientific International
Manufacturing Coordinator: Margie Orzech
Prepress Vendor: Aptara, Inc.

Twelfth Edition

Copyright © 2017 Wolters Kluwer.

Copyright © 2013, 2009 by Wolters Kluwer Health/Lippincott Williams & Wilkins. Copyright © 2007,
2003, 1999 by Lippincott Williams & Wilkins. Copyright © 1995, 1991, 1987, 1983, 1979, 1974 by J. B.
Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be
reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other
electronic copies, or utilized by any information storage and retrieval system without written permission
from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials
appearing in this book prepared by individuals as part of their official duties as U.S. government employees
are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at
Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or
via our website at lww.com (products and services).

9 8 7 6 5 4 3 2 1

Printed in China

Library of Congress Cataloging-in-Publication Data
Names: Bickley, Lynn S., author. | Szilagyi, Peter G., author. | Hoffman,
Richard M., editor.
Title: Bates’ guide to physical examination and history taking / Lynn S.
Bickley, Peter G. Szilagyi ; guest editor, Richard M. Hoffman.
Other titles: Guide to physical examination and history taking
Description: Twelfth edition. | Philadelphia : Wolters Kluwer, [2017] |
Includes bibliographical references and index.
Identifiers: LCCN 2016018376 | ISBN 9781469893419 (alk. paper)
Subjects: | MESH: Physical Examination—methods | Medical History
Taking–methods
Classification: LCC RC76 | NLM WB 205 | DDC 616.07/54—dc23
LC record available at https://lccn.loc.gov/2016018376

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied,
including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.
This work is no substitute for individual patient assessment based upon healthcare professionals’
examination of each patient and consideration of, among other things, age, weight, gender, current or prior
medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher
does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals,
and not the publisher, are solely responsible for the use of this work including all medical judgments and for
any resulting diagnosis and treatments.
Given continuous, rapid advances in medical science and health information, independent professional
verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and
treatment options should be made and healthcare professionals should consult a variety of sources. When
prescribing medication, healthcare professionals are advised to consult the product information sheet (the
manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use,
warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if
the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the
maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury
and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from
any reference to or use by any person of this work.

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

art of medicine.

vii

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 and Palliative Care
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, FAAD

Associate Professor and Founding Chair
Department of Dermatology
Hofstra Northwell School of Medicine
Northwell Health
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

Mark Landig, OD

Division of Cataract & Refractive Surgery
Jules Stein Eye Institute
David Geffen School of Medicine
Los Angeles, California

Helen R. Levey, DO, MPH

PGY5 Resident in Urology
School of Medicine and Dentistry
University of Rochester Medical Center
Rochester, New York

Patrick McCleskey, MD

Dermatologist
Kaiser Permanente 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 Residency
Associate Professor
Department of Medicine
School of Medicine and Dentistry
University of Rochester Medical Center
Rochester, New York

viii Faculty Reviewers

A. Andrew Rudmann, MD

Associate Professor
Department of Medicine
School of Medicine and Dentistry
University of Rochester Medical Center
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, MS, FACS

Partner
Genesee Surgical Associates
Rochester, New York

Paula Zozzaro-Smith, DO

Fellow of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
University of Rochester Medical Center
Rochester, New York

STUDENT REVIEWERS

Ayala Danzig

University of Rochester School of Medicine and Dentistry

Benjamin Edmonds

University of Central Florida College of Medicine

Nicholas PN Goldstein

University of Rochester School of Medicine and Dentistry

ix

Preface

Bates’ Guide to Physical Examination and History Taking is designed for medical,
physician assistant, nurse practitioner, and other students who are learning to
interview patients, perform their physical examination, and apply clinical rea-
soning and shared decision making to their assessment and plan, based on a
sound understanding of clinical evidence. The twelfth edition has many new
features to facilitate student learning. As with previous editions, these changes
spring from three sources: the feedback and reviews of students, teachers, and
faculty; our commitment to making the book easier to read and more efficient to
use; and the abundant new evidence that supports the techniques of examina-
tion, interviewing, and health promotion.

Throughout the twelfth edition, we emphasize common or important problems
rather than the rare or esoteric, though at times we include unusual findings that
are classic or life threatening. We encourage students to study the strong evi-
dence base that informs each chapter and to carefully review the clinical guide-
lines and citations from the health care literature.

Special Features and Highlights

In this edition we have introduced clinical pearls, printed in blue, to highlight key
points. We have also used color to highlight textboxes so students and teachers
can quickly find important summaries of clinical conditions and tips for chal-
lenging examination techniques such as inspecting the fundus or measuring the
jugular venous pressure. Many of the figures are new or have been updated and,
for the first time, all figures are numbered with captions to make them easier to
locate and reference in both the print and electronic editions.

Organization

The book comprises three units: Foundations of Health Assessment, Regional Exam-
inations, and Special Populations.

Unit 1, Foundations of Health Assessment, includes chapters on clinical proficiency,
assessing clinical evidence, and interviewing and health history. These chapters fol-
low a logical sequence that begins with an overview of the components of patient
evaluation, followed by important concepts in assessment of clinical evidence and
clinical decision making, and the artful task of gathering the history.

â–  Chapter 1, Foundations for Clinical Proficiency, features an overview of history
taking, physical examination, and now includes the assessment and plan,
and a sample patient record. This chapter describes the differences between

x Preface

subjective and objective data and symptoms and signs, and provides a model
for sequencing the examination that optimizes patient comfort. It presents
guidelines for creating a clear, succinct, and well-organized patient record.

â–  Chapter 2, Evaluating Clinical Evidence, has been entirely rewritten in the
twelfth edition by Dr. Richard Hoffman and clarifies key concepts to ensure
student understanding of the history and physical examination as diagnostic
tests; tools for evaluating diagnostic tests such as sensitivity, specificity, posi-
tive and negative predictive values, and likelihood ratios; types of studies that
inform recommendations for health promotion; and an approach to critical
appraisal of the clinical literatures and types of bias.

â–  Chapter 3, Interviewing and the Health History, describes the differences
between a comprehensive and focused health history, and between the fluid
exchange of the interview and its transformation into the structured format of
the written health history. It presents the techniques of skilled and advanced
interviewing, the sequence and context of the interview, including its cultural
dimensions, and foundational concepts of ethics and professionalism. It clar-
ifies the transition from the open-ended interviewing of the Present Illness
(and Personal and Social History) to the direct questions of the Past Medical
History and Family History to the closed-ended “yes–no” questions of the
Review of Systems. This chapter emphasizes the importance of masterful lis-
tening, so easily sacrificed to the time pressures of office and hospital care. It
mirrors the precepts of Sir William Osler . . . for therapeutic relationships,
always “Listen to your patient. He is telling you the diagnosis,” and “The good
physician treats the disease. The great physician treats the patient who has the
disease.”

Unit 2, Regional Examinations covers the regional examinations from “head to
toe.” The 14 chapters in this unit have been thoroughly updated and contain a
review of anatomy and physiology, the common symptoms encountered in the
health history, important topics for health promotion and counseling, detailed
descriptions and images of techniques of examination, a sample written record,
comparative tables of abnormalities, and conclude with extensive references
from the recent clinical literature. Chapters with the most significant revisions
are highlighted below.

â–  Chapter 4, Beginning the Physical Examination: General Survey, Vital Signs, and
Pain, contains updates on obesity and nutrition counseling, and new stan-
dards for measuring blood pressure from the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure VII Report
( J NC 8).

â–  Chapter 5, Behavior and Mental Status, has been substantially revised accord-
ing to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
(DSM-5) of 2013.

â–  Chapter 6, The Skin, Hair, and Nails, has been entirely rewritten for the twelfth
edition by Dr. Patrick McCleskey and Dr. Amit Garg to improve the frame-
work for assessing common lesions and abnormalities and the quality of its

P r e f a c e xi

teaching photographs, and to align this chapter with recommendations of the
American Academy of Dermatology for student learners.

â–  Chapter 9, The Cardiovascular System, has detailed new evidence about risk
factor screening, new clinical guidelines, and the complexities of assessing
hypertension.

â–  Chapter 16, The Musculoskeletal System, contains a more systematic approach
to the musculoskeletal examination and an updated classification of maneu-
vers to assess the shoulder, with reference to likelihood ratios for abnormali-
ties whenever permitted by the clinical literature.

Other notable features include discussion of new screening guidelines for breast
cancer, prostate cancer, colon cancer, Papanicolaou smears, and stroke risk fac-
tors as well as updated information on sexually transmitted diseases.

Unit 3, Special Populations includes chapters covering special stages in the life
cycle—infancy through adolescence, pregnancy, and aging.

â–  Chapter 18, Assessing Children: Infancy through Adolescence, includes an increased
emphasis on health promotion and child development, as well as the many tables
and figures that highlight key concepts.

â–  Chapter 19, The Pregnant Woman, updates health promotion and counseling
topics such as nutrition, weight gain, immunizations, substance abuse, and
intimate partner violence.

â–  Chapter 20, The Older Adult, presents new information on frailty, when to
screen, immunizations and cancer screening, the spectrum of cognitive
decline and dementia screening tests, and the new algorithm for falls preven-
tion from the Centers for Disease Control and Prevention. This chapter and
Chapter 17, The Nervous System, also explore the challenging complexities of
distinguishing delirium, dementia, and depression.

Additional Resources

Bates’ Pocket Guide to Physical Examination and History Taking

As a companion to Bates’ twelfth edition, we recommend Bates’ Pocket Guide to
Physical Examination and History Taking, Eighth edition. The Pocket Guide is an
abbreviated version of the Bates’ twelfth edition textbook, which is designed for
portability and convenience at the bedside. Return to the textbook whenever
more comprehensive study and understanding are needed.

Bates’ Visual Guide to Physical Examination

The Bates’ Visual Guide to Physical Examination (www.batesvisualguide.com),
refilmed in 2013, is a key adjunct for mastering the many techniques of physical
examination. This series of 18 videos displays seasoned clinicians conducting
each of the regional examinations and demonstrates visually the varying tech-
niques of inspection, palpation, percussion, and auscultation in the regional

xii Preface

examinations and special populations. We encourage students to study the writ-
ten chapters and videos in tandem, often numerous times.

For students preparing for clinical testing, the Visual Guide includes 10 Objec-
tive Structured Clinical Examinations (or OSCEs), which shows students evalu-
ating patients with common clinical problems in standard OSCE formats,
interspersed with questions to guide learning key points. These OSCEs cover:

1. Chest Pain
2. Abdominal Pain
3. Sore Throat
4. Knee Pain
5. Cough
6. Vomit
7. Amenorrhea
8. Falls
9. Back Pain
10. Shortness of Breath

xiii

Acknowledgments

Bates’ Guide to Physical Examination and History Taking, now in its twelfth edition,
spans an evolution of four decades. Drs. Barbara Bates and Robert Hoekelman,
colleagues in internal medicine and pediatrics at the University of Rochester
School of Medicine and Dentistry, launched the first edition in 1974 as a hands-
on manual for medical and advanced practice nursing students learning to mas-
ter the physical examination of adults and children. With clear prose and black
and white drawings, they devoted 18 chapters to the techniques of regional
examination for adults and children. They devised the classic format of the Bates’
Guide still present today—black explanatory text in the major column, examples
of abnormalities in red in the minor column, and comparative tables of abnor-
malities at the end of each chapter. Dr. Bickley became chief editor and author
for the seventh edition, joined by Dr. Szilagyi for the eighth edition. By then the
Bates’ Guide contained additional sections on anatomy and physiology and new
chapters on interviewing, the approach to symptoms, the mental status examina-
tion, and clinical thinking from data to plan.

Over the next four editions Drs. Bickley and Szilagyi added many features to
make Bates’ Guide useful to student learners. They introduced health history and
health promotion and counseling sections in each chapter, and have increasingly
accommodated the evidence-based medicine “revolution” with updated health
promotion and counseling sections in each edition that cite major studies and
clinical guidelines; examples of abnormalities, tables, and footnotes and refer-
ences reflecting advances in the clinical literature; and now a new chapter on
evaluating clinical evidence.

In this edition with pleasure and esteem the authors welcome Dr. Richard
Hoffman, Professor of Internal Medicine and Epidemiology and Director of the
Division of General Internal Medicine at the University of Iowa Carver College
of Medicine/Iowa City VA Medical Center, as guest editor. Dr. Hoffman is
Associate Editor for the American College of Physicians (ACP) Journal Club, and
has been a peer reviewer for a number of prostate screening guidelines, authored two
Cochrane reviews, and writes and reviews for UpToDate.

Each edition of the Bates’ Guide builds on an extensive review process, with many
thanks due. First, the publisher surveys students and faculty about the merits of
each chapter. Summaries of their responses provide helpful recommendations
for subsequent revisions. Then the authors elicit intensive chapter critiques and
updates from faculty at health sciences schools across the country, listed in the
Reviewers section to follow. For their valuable insights and intense focus on this
edition, the authors especially commend Dr. Richard Hoffman for his lucid pre-
sentation of the complex concepts governing evaluation of clinical evidence in

xiv Acknowledgments

Chapter 2, Dr. Patrick McCleskey for rewriting Chapter 6 and presenting a new
paradigm for assessing skin lesions with many new teaching photographs,
assisted by Dr. Amit Garg. Drs. John Bartlett and Mark Landig for their review of
the head and neck examination in Chapter 7, Dr. J.D. Bartleson for refining the
always challenging fundamentals of the examination of the nervous system in
Chapter 17, and Drs. Carla Herman and John Robertson for their useful scrutiny
of new developments in the evaluation of older adults in Chapter 20. We also
appreciate the assistance of Dr. Alec O’Connor in locating skilled faculty review-
ers for many of the adult examination chapters and making important contribu-
tions to revisions of Chapter 8. Several reviewers made valued additions to the
assessment of children and adolescents in Chapter 18—Dr. Moira Szilagyi and
medical students Nicholas Goldstein and Ayala Danzig.

To compose and produce the Bates’ Guide requires the deft touch of a maestro.
Newly revised chapters must be reviewed, author queries issued and answered,
and photos and illustrations checked and rechecked for teaching style and accu-
racy. Text, textboxes, examples of abnormalities, and images all must be carefully
aligned. Each page is designed to hold reader appeal, highlight key points, and
facilitate student learning. For his untiring craft and dedication, we especially
thank Greg Nicholl, Senior Product Development Editor at Wolters Kluwer, who
has woven these many strands into a coherent and exemplary text. We commend
Kelly Horvath who assisted Greg with line-by-line review and careful annota-
tions to prepare the book for the compositor, and Chris Miller of Aptara who
turned complex text documents into corrected print proofs ready for publica-
tion. Early in the editing process and preceding Greg Nicholl, Stephanie Roulias
was a conscientious collaborator who set many of the editing processes for the
twelfth edition in motion. Crystal Taylor has been an astute manager of acquisi-
tions for the Bates’ Suite of teaching materials, contracting, and marketing. The
publishing team brings invaluable talent to the tradition of excellence that has
made the Bates’ Guide a premier text for students learning the time-honored skills
of patient assessment and care.

The twelfth edition of Bates’ Guide to Physical Exami-
nation and History Taking is your comprehensive

guide to learning to effectively conduct the health
interview and physical examination. This section
introduces you to the features and learning tools

that will lead to successful health assessments,
regional examinations, and working with special

patient populations.

At the start of every chapter, you will see a list of
additional learning resources that complement

the book in order to build your knowledge and
confidence in history taking and examination.
The Bates’ Visual Guide to Physical Examination

offers over 8 hours of video content and deliv-
ers head-to-toe and systems-based physical

examination techniques. When used along-
side the book, you have a complete learning

solution for preparedness for the boards
and patient encounters.

How To Use
Bates’ Guide To Physical Examination

And History Taking

Clinical Pearls—NEW!

Be sure to pay special attention to the clinical pearls,
printed in blue. These clinical comments provide

practical “pearls” that enhance your understanding
of the assessment techniques.

because e a o a ca appea a y ocat o . g s pat e ts a e t ose
with a personal or family history of multiple or dysplastic nevi or previous
melanoma. Patients who have a clinical skin examination within the 3 years
prior to a melanoma diagnosis have thinner melanomas than those who did
not have a clinical skin examination.20 Both new and changing nevi should be
closely examined, as at least half of melanomas arise de novo from isolated
melanocytes rather than pre-existing nevi. Also consider “opportunistic
screening” as part of the complete physical examination for patients with
significant sun exposure and patients over age 50 years without prior skin
examination or who live alone.

Since the USPSTF review, an important German study of over 350,000 patients
reported that full-body primary care screening with dermatology referrals for
concerning lesions reduced melanoma mortality by more than 47%.21 Survival
from melanoma strongly correlates with tumor thickness. Two further studies
demonstrate that patients receiving skin examinations are more likely to have
thinner melanomas.20,22

Detecting melanoma requires practice and knowledge of how benign nevi
change over time, often going from flat to raised or acquiring additional brown
pigment. Studies have shown that even limited clinician training makes a dif-
ference in detection: patients of primary care providers who spent 1.5 hours
completing an online tutorial improved diagnostic accuracy. Similar studies
show such training results in thinner melanomas than patients of providers
without such training.23–26

Screening for Melanoma: The ABCDEs. Clinicians should apply the
ABCE-EFG method when screening moles for melanoma (this does not apply
for non-melanocytic lesions like seborrheic keratoses). The sensitivity of this
tool for detecting melanoma ranges from 43% to 97%, and specificity ranges
from 36% to 100%; diagnostic accuracy depends on how many criteria are used

d fi b l 27 f f h f b

Turn to Tables 6-4 through 6-6 on

pp. 197–203 showing rough, pink,

and brown nevi and their mimics.

Review the ABCDE-EFG rule and pho-

tographs in Table 6-6, pp. 200–203,

which provide additional helpful

identifiers and comparisons of benign

brown lesions with melanoma.

pp y g p
h l f l h f l l d l

because e a o a ca appea a y ocat o . g s pat e ts a e t ose

al Exami-
ehensive
e health
section
g tools

ments,
pecial
ions.

st of
ent
nd
n.
n

C H A P T E R 11 |

The Abdomen

449

Visualize or palpate the bony landmarks of the abdominal wall and pelvis, as

shown in Figure 11-1: the xiphoid process, iliac crest, anterior superior iliac spine,

pubic tubercle, and symphysis pubis. The rectus abdominis muscles become more

prominent when the patient raises the head and shoulders or lifts the legs from

the supine position.

C H A P T E R

11The AbdomenThe Bates’ suite offers these additional resources to enhance learning and facilitate understanding of this chapter:■ Bates’ Pocket Guide to Physical Examination and History Taking, 8th edition■ Bates’ Visual Guide to Physical Examination (Vol. 13: Abdomen)■ thePoint online resources, for students and instructors: http://thepoint.lww.comAnatomy and Physiology
Rectus abdominis

muscle

Umbilicus

Inguinal ligament
Pubic tubercle

Xiphoid process

Costal margin

Midline, overlyinglinea alba

Anterior superioriliac spine

Symphysis pubis

Iliac crest

F I G U R E 1 1 – 1 . Landmarks of the abdomen.

LWBK1481-Ch11_p449-508.indd 449

xv

C H A P T E R 17 |

The Nervous System 785

Table 17-7 Nystagmus

Nystagmus is a rhythmic oscillation of the eyes, analogous to a tremor in other parts of the body. It has multiple causes,
including impairment of vision in early life, disorders of the labyrinth and the cerebellar system, and drug toxicity. Nystagmus
occurs normally when a person watches a rapidly moving object (e.g., a passing train). Study the three characteristics of
nystagmus described in this table so that you can correctly identify the type of nystagmus. Then refer to textbooks of neurology
for differential diagnoses.

Direction of Gaze in Which Nystagmus Appears
Example: Nystagmus on Right Lateral Gaze

Nystagmus Present (Right Lateral Gaze)

Although nystagmus may be present in all
directions of gaze, it may appear or become
accentuated only on deviation of the eyes (e.g.,
to the side or upward). On extreme lateral
gaze, the normal person may show a few beats
resembling nystagmus. Avoid making
assessments in such extreme positions, and
observe for nystagmus only within the field of full
binocular vision.

Nystagmus Not Present (Left Lateral Gaze)

Direction of the Quick and Slow Phases
Example: Left-Beating Nystagmus—a Quick Jerk to the Left in

Each Eye, then a Slow Drift to the Right

Nystagmus usually has both slow and fast
movements, but is defined by its fast phase.
For example, if the eyes jerk quickly to the
patient’s left and drift back slowly to the right,
the patient is said to have left-beating
nystagmus. Occasionally, nystagmus consists
only of coarse oscillations without quick and
slow components, described as pendular.

(continued)

Examples of Abnormalities

Once again, Bates’ Guide to Physical Examination and
History Taking offers an easy-to-follow two-column

format with step-by-step examination techniques on
the left and abnormalities with differential diagnoses

on the right. As your skills progress, study the
abnormal variants of common physical findings in

the red Examples of Abnormalities column to deepen
your knowledge of important clinical conditions.

multipiplle causes,
ug ttoxoxiicity. Nystagmus
chaaraaccteristics of
teexttbbooks of neurology

may be present in all
may appear or become
deviation of the eyes (e.g.,
) On extreme lateral

ies

n and
umn
s on
ses
the
in

en
s.

C H A P T E R 17 |

The Nervous System 737

TECHNIQUES OF EXAMINATION
Cranial Nerves III, IV, and VI—Oculomotor, Trochlear, and Abdu-

cens. Test the extraocular movements in the six cardinal directions of gaze, and

look for loss of conjugate movements in any of the six directions, which causes

diplopia. Ask the patient which direction makes the diplopia worse and inspect

the eye closely for asymmetric deviation of movement. Determine if the diplo-

pia is monocular or binocular by asking the patient to cover one eye, then the

other.

Check convergence of the eyes.

Identify any nystagmus, an involuntary jerking movement of the eyes with quick

and slow components. Note the direction of gaze in which it appears, the plane

of the nystagmus (horizontal, vertical, rotary, or mixed), and the direction of the

quick and slow components. Nystagmus is named for the direction of the quick

component. Ask the patient to fix his or her vision on a distant object and

observe if the nystagmus increases or decreases.
Look for ptosis (drooping of the upper eyelids). A slight difference in the width

of the palpebral fissures is a normal variant in approximately one third of patients.
Cranial Nerve V—TrigeminalMotor. While palpating the temporal and masseter muscles in turn, ask the

patient to firmly clench the teeth (Figs. 17-9 and 17-10). Note the strength of

muscle contraction. Ask the patient to open and move the jaw from side to side.

See Chapter 7, Head and Neck (pp. 237–
238) for a more detailed discussion of
testing extraocular movements.

See Table 7-11, Dysconjugate Gaze,
p. 278. Monocular diplopia is seen in
local problems with glasses or contact
lenses, cataracts, astigmatism, or pto-
sis. Binocular diplopia occurs in CN III, IV,
and VI neuropathy (40% of patients), and eye muscle disorders from myas-thenia gravis, trauma, thyroid ophthal-mopathy, and internuclear ophthalmoplegia.86

See Table 17-7, Nystagmus, pp. 785–786.
Nystagmus is seen in cerebellar dis-ease, especially with gait ataxia and dysarthria (increases with retinal fixa-

tion), and vestibular disorders (decreases with retinal fixation); and in internuclear ophthalmoplegia.
Ptosis is seen in 3rd nerve palsy (CN III),
Horner syndrome (ptosis, miosis, forehead anhidrosis), or myasthenia gravis.

F I G U R E 1 7 – 9 . Palpate the
temporal muscles.

F I G U R E 1 7 – 1 0 . Palpate the
masseter muscles.

Difficulty clenching the jaw or moving
it to the opposite side suggests mas-
seter and lateral pterygoid weakness,
respectively. Jaw deviation during opening points to weakness on the

deviating side.

Look for unilateral weakness in CN V
pontine lesions; bilateral weakness in
bilateral hemispheric disease.

CNS patterns from stroke include ipsi-
lateral facial and body sensory loss
from contralateral cortical or thalamic
lesions; ipsilateral face, but contralat-
eral body sensory loss in brainstem
lesions.

E X A M P L E S O F A B N O R M A L I T I E S

K1481-Ch17_p711-796.indd 737

To further sharpen your clinical acumen, turn
to the end-of-chapter Tables of Abnormalities,
which allow you to compare and contrast
clinical conditions in a convenient single table
format.

xvi

322 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

TECHNIQUES OF EXAMINATION

percuss first in one location, then in another. Review the description of per-
cussion notes on p. 323. Healthy lungs are resonant.

While the patient keeps both arms crossed in front of the chest, percuss the
thorax in symmetric locations on each side from the apex to the base.

â–  Percuss one side of the chest and then
the other at each level in a ladder-like
pattern, as shown in Figure 8-19.
Omit the areas over the scapulae—
the thickness of muscle and bone
alters the percussion notes over the
lungs. Identify and locate the area
and quality of any abnormal per-
cussion note.

â–  Identify the descent of the diaphragm, or diaphragmatic excursion. First, deter-
mine the level of diaphragmatic dullness during quiet respiration. Holding the
pleximeter finger above and parallel to the expected level of dullness, percuss
downward in progressive steps until dullness clearly replaces resonance.
Confirm this level of change by percussing downward from adjacent areas
both medially and laterally (Fig. 8-20).

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 accumula-

tions of serous fluid (pleural effusion),
blood (hemothorax), pus (empyema),
fibrous tissue, or tumor. Dullness

makes pneumonic and pleural

effusion three to four times more

likely, respectively.45

Generalized hyperresonance is com-
mon over the hyperinflated lungs of

COPD or asthma. Unilateral hyperreso-
nance suggests a large pneumothorax
or an air-filled bulla.

1

2

3

4

5

1

2

3

4

5

6 6

7 7

F I G U R E 8 – 1 9 . Percuss and

auscultate in a “ladder” pattern.

Resonant

Level of
diaphragm

Dull

Location
and sequence
of percussion

F I G U R E 8 – 2 0 . Identify the extent of diaphragmatic excursion.

This technique tends to overestimate

actual movements of the diaphragm.45

Dull

F I G U R E 8 – 2 1 . Absent descent

of the diaphragm can indicate pleural

effusion.

An abnormally high level suggests a

pleural effusion or an elevated hemidi-
aphragm from atelectasis or phrenic
nerve paralysis (Fig. 8-21).

E X A M P L E S O F A B N O R M A L I T I E S

Examination
Techniques

The Techniques of Examina-
tion sections are where you
will learn the crucial and
relevant examinations you
will perform every day.
Additional Special Tech-
niques offer the examina-
tion approach for more
uncommon conditions
and special circumstances.

248 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

ANATOMY AND PHYSIOLOGY

Ask where the patient hears the sound: on one side or both sides? Normally, the
vibration is heard in the midline or equally in both ears. If nothing is heard, try
again, pressing the fork more firmly on the head. Restrict this test to patients with
unilateral hearing loss since patients with normal hearing may lateralize, and
patients with bilateral conductive or sensorineural deficits will not lateralize.

â–  Compare AC and BC (Rinne test). Place the base of a lightly vibrating tuning fork
on the mastoid bone, behind the ear and level with the canal (Fig. 7-45). When
the patient can no longer hear the sound, quickly place the fork close to the ear
canal and ask if the patient hears a vibration (Fig. 7-46). Here, the “U” of the
fork should face forward, which maximizes sound transmission for the patient.
Normally, the sound is heard longer through air than through bone (AC > BC).

In unilateral sensorineural hearing
loss, sound is heard in the good ear.

F I G U R E 7 – 4 5 . Test bone conduction. F I G U R E 7 – 4 6 . Test air conduction.

In conductive hearing loss, sound is
heard through bone as long as or lon-

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

(AC > BC).

The Nose and Paranasal Sinuses

Anatomy and Physiology. Review
the terms that describe the external
anatomy of the nose (Fig. 7-47).

Approximately the upper third of the
nose is supported by bone, the lower two
thirds by cartilage. Air enters the nasal
cavity through the anterior naris on either
side, then passes into the widened area
known as the vestibule and on through
the narrow nasal passage to the naso-
pharynx.

Ala nasi

Vestibule

Anterior
naris

Tip

Bridge

Dorsum

F I G U R E 7 – 4 7 . External anatomy of the nose.

E X A M P L E S O F A B N O R M A L I T I E S

Photographs
and Illustrations

The art program includes
detailed, full-color photo-

graphs, drawings, and dia-
grams, some new or revised,

to further illustrate key points
in the text. They will enhance

your learning potential by
providing accurate and realis-

tic representations.

And now, each figure has a
figure number and caption to
make the figures easier to find

and understand.

TTEEECH

p
cu

W
th

â– â–  P
th
p
O
th
al
lu
an
cu

â– â–  Id
m
p
d
C
b

320 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

TECHNIQUES OF EXAMINATION

â–  Palpate both lungs for symmetric tac-
tile fremitus (Fig. 8-15). Fremitus
refers to the palpable vibrations
that are transmitted through the
bronchopulmonary tree to the
chest wall as the patient is speaking
and is normally symmetric. Fremi-
tus is typically more prominent in
the interscapular area than in the
lower lung fields and easier to de-
tect over the right lung than the left.
It disappears below the diaphragm.

To detect fremitus, use either the
ball (the bony part of the palm at
the base of the fingers) or the ulnar
surface of your hand to optimize the vibratory sensitivity of the bones in
your hand. Ask the patient to repeat the words “ninety-nine” or “one-one-
one.” Initially practice with one hand until you feel the transmitted vibra-
tions. Use both hands to palpate and compare symmetric areas of the lungs in
the pattern shown in the photograph. Identify and locate any areas of
increased, decreased, or absent fremitus. If fremitus is faint, ask the patient
to speak more loudly or in a deeper voice.

Tactile fremitus is a somewhat imprecise assessment technique, but does
direct your attention to possible asymmetries. Confirm any disparities by
listening for underlying breath sounds, voice sounds, and whispered voice
sounds. All these attributes should increase or decrease together.

Percussion. Percussion is one of the most important techniques of physical
examination. Percussion sets the chest wall and underlying tissues in motion,
producing audible sound and palpable vibrations. Percussion helps you estab-
lish whether the underlying tissues are air-filled, fluid-filled, or consolidated.
The percussion blow penetrates only 5 to 7 cm into the chest, however, and will
not aid in detection of deep-seated lesions.

The technique of percussion can be practiced on any surface. As you practice,
listen for changes in percussion notes over different types of materials or different
parts of the body. The key points for good technique, described for a right-
handed person, are detailed below:

â–  Hyperextend the middle finger of
your left hand, known as the plexim-
eter finger. Press its distal interpha-
langeal joint firmly on the lung
surface to be percussed (Fig. 8-16).
Avoid surface contact by any other part
of the hand because this dampens out
vibrations. Note that the thumb and
second, fourth, and fifth fingers are
not touching the chest wall.

Fremitus is decreased or absent when

the voice is higher pitched or soft or

when the transmission of vibrations

from the larynx to the surface of the

chest is impeded by a thick chest wall,

an obstructed bronchus, COPD, or
pleural effusion, fibrosis, air (pneumo-
thorax), or an infiltrating tumor.

1

2

3

1

2

3

44

F I G U R E 8 – 1 5 . Locations for

palpating fremitus.

Asymmetric decreased fremitus raises
the likelihood of unilateral pleural
effusion, pneumothorax, or neoplasm,
which decreases transmission of low-

frequency sounds; asymmetric

increased fremitus occurs in unilateral
pneumonia which increases transmis-

sion through consolidated tissue.44

F I G U R E 8 – 1 6 . Press the pleximeter

finger firmly on the chest wall.

E X A M P L E S O F A B N O R M A L I T I E S

hheeaarrrinngg
ggooooodd eeear.

ssoouunndd is

nggg aasss oorr lon-

BCCC == AACCC or
heeearrrininggg loss,
ouuughh aair

MMM AA LLL I TTT I E S

C H A P T E R 7 |

The Head and Neck 249

ANATOMY AND PHYSIOLOGY

The medial wall of each nasal cavity is formed by
the nasal septum, which, like the external nose, is
supported by both bone and cartilage (Fig. 7-48).
It is covered by a mucous membrane well supplied
with blood. The vestibule, unlike the rest of the
nasal cavity, is lined with hair-bearing skin, not
mucosa.

Laterally, the anatomy is more complex (Fig. 7-49).
Curving bony structures, the turbinates, covered by a
highly vascular mucous membrane, protrude into the
nasal cavity. Below each turbinate is a groove, or
meatus, each named according to the turbinate above
it. The nasolacrimal duct drains into the inferior
meatus; most of the paranasal sinuses drain into the
middle meatus. Their openings are not usually visible.

The additional surface area provided by the turbinates
and their overlying mucosa aids the nasal cavities in
their principal functions: cleansing, humidification,
and temperature control of inspired air.

The paranasal sinuses are air-filled cavities within the bones of the skull. Like the
nasal cavities into which they drain, they are lined with mucous membrane.
Their locations are diagrammed in Figure 7-50. Only the frontal and maxillary
sinuses are readily accessible to clinical examination (Fig. 7-51).

Cranial cavity

Sphenoid sinus

Bony portion
of nasal septum

Soft palate
Hard palate

Cartilaginous portion
of nasal septum

Frontal sinus

F I G U R E 7 – 4 8 . Medial wall—left nasal cavity (mucosa removed).

Cranial cavity

Opening to
eustachian
tube

Hard palate

Vestibule

Inferior turbinate

Middle turbinate

Superior turbinate

Frontal sinus

Nasopharynx

Soft
palate

F I G U R E 7 – 4 9 . Lateral wall—nasal cavity.

Frontal
sinus

Orbit

Middle
turbinate
Maxillary
sinus

Inferior
turbinate

Inferior
meatus

Middle
meatus

Ethmoid
sinus

F I G U R E 7 – 5 0 . Cross-section of nasal cavity—anterior view.

Frontal
sinus

Maxillary
sinus

F I G U R E 7 – 5 1 . Frontal and maxillary sinuses.

xvii

References

Consult the References at the end of the
chapters to deepen your knowledge of

important clinical conditions. The habit
of searching the clinical literature will

serve you and your patients well
throughout your career.

C H A P T E R 17 |

The Nervous System 773

RECORDING YOUR FINDINGS

Recording Your Findings
Note that initially you may use sentences to describe your findings; later you
will use phrases. The style below contains phrases appropriate for most write-
ups. Note the five components of the examination and write-up of the nervous
system.

Recording the Examination—The Nervous System

“Mental Status: Alert, relaxed, and cooperative. Thought process coherent. Ori-
ented to person, place, and time. Detailed cognitive testing deferred. Cranial
Nerves: I—not tested; II through XII intact. Motor: Good muscle bulk and
tone. Strength 5/5 throughout. Cerebellar—Rapid alternating movements

(RAMs), finger-to-nose (F→N), heel-to-shin (H→S) intact. Gait with normal
base. Romberg—maintains balance with eyes closed. No pronator drift.

Sensory: Pinprick, light touch, position, and vibration intact. Reflexes: 2 and
symmetric with plantar reflexes downgoing.”

OR
“Mental Status: The patient is alert and tries to answer questions but has difficulty

finding words. Cranial Nerves: I—not tested; II—visual acuity intact; visual fields
full; III, IV, VI—extraocular movements intact; V motor—temporal and masseter

strength intact, corneal reflexes present; VII motor—prominent right facial

droop and flattening of right nasolabial fold, left facial movements intact, sen-

sory—taste not tested; VIII—hearing intact bilaterally to whispered voice; IX,

X—gag intact; XI—strength of sternocleidomastoid and trapezius muscles 5/5;

XII—tongue midline. Motor: strength in right biceps, triceps, iliopsoas, gluteals,
quadriceps, hamstring, and ankle flexor and extensor muscles 3/5 with good

bulk but increased tone and spasticity; strength in comparable muscle groups

on the left 5/5 with good bulk and tone. Gait—unable to test. Cerebellar—

unable to test on right due to right arm and leg weakness; RAMs, F→N, H→S
intact on left. Romberg—unable to test due to right leg weakness. Right prona-

tor drift present. Sensory: decreased sensation to pinprick over right face, arm,
and leg; intact on the left. Stereognosis and two-point discrimination not

tested. Reflexes (can record in two ways):

RT ++++ ++++ ++++ ++++ ++++
LT ++ ++ ++ ++ +

OR

PlantarBiceps Triceps Brach Knee Ankle 4+
4+

4+

4+

4+

2+
2+
2+

These findings are suspicious for left

hemispheric cerebral infarction in the

distribution of the left middle cerebral

artery, with right-sided hemiparesis.

E X A M P L E S O F A B N O R M A L I T I E S Recording Your Findings

Constructing a well-organized clinical record
must clearly display important clinical infor-
mation and your clinical reasoning and plan.
You will gain this skill and learn the descrip-
tive vocabulary of physical findings in the
Recording Your Findings section of each of the
regional examination and special populations’
chapters.

REFERENCES

References
1. Clark D 3rd, Ahmed MI, Dell’italia LJ, et al. An argument for

reviving the disappearing skill of cardiac auscultation. Cleve Clin
J Med. 2012;79:536.

2. Delora A. The decline of cardiac auscultation: ‘the ball of the
match point is poised on the net’. J Cardiovasc Med. 2008;9:1173.

3. Markel H. The stethoscope and the art of listening. N Engl J Med.
2006;354:551.

4. Simel DL. Time, now, to recover the fun in the physical examina-
tion rather than abandon it. Arch Intern Med. 2006;166:603.

5. Vukanovic-Criley JM, Hovanesyan A, Criley SR, et al. Confiden-
tial testing of cardiac examination competency in cardiology and
noncardiology faculty and trainees: a multicenter study. Clin Car-
diol. 2010;33:738.

6. Wayne DB, Butter J, Cohen ER, et al. Setting defensible standards
for cardiac auscultation skills in medical students. Acad Med.
2009;84(10 Suppl):S94.

7. Marcus G, Vessey J, Jordan MV, et al. Relationship between accu-
rate auscultation of a clinically useful third heart sound and level
of experience. Arch Intern Med. 2006;166:617.

8. Vukanovic-Criley JM, Criley S, Warde CM, et al. Competency in
cardiac examination skills in medical students, trainees, physi-
cians, and faculty. A multicenter study. Arch Intern Med.
2006;166:610.

9. March SK, Bedynek JL Jr, Chizner MA. Teaching cardiac ausculta-
tion: effectiveness of a patient-centered teaching conference on
improving cardiac auscultatory skills. Mayo Clin Proc. 2005;
80;1443.

10. RuDusky BM. Auscultation and Don Quixote. Chest. 2005;127:
1869.

11. Mangione S. Cardiac auscultatory skills of physicians-in-training:
a comparison of three English speaking countries Am J Med

20. Saxena A, Barrett MJ, Patel AR, et al. Merging old school methods
with new technology to improve skills in cardiac auscultation.
Semin Med Pract. 2008;11:21.

21. Vukanovic-Criley JM, Boker JR, Criley SR, et al. Using virtual
patients to improve cardiac examination competency in medical
students. Clin Cardiol. 2008;31:334.

22. Barrett MJ, Lacey CS, Sekara AE, et al. Mastering cardiac mur-
murs. The power of repetition. Chest. 2004;126:470.

23. Lee E, Michaels AD, Selvester RH, et al. Frequency of diastolic
third and fourth heart sounds with myocardial ischemia induced
during percutaneous coronary intervention. J Electrocardiol.
2009;42:39.

24. Marcus GM, Gerber IL, McKeown BH, et al. Association between
phonocardiographic third and four heart sound and objective
measure of left ventricular function. JAMA. 2005;293:2238.

25. Shah SJ, Marcus GM, Gerber IL, et al. Physiology of the third heart
sound: novel insights from tissue Doppler imaging. J Am Soc Echo-
cardiogr. 2008;21:394.

26. Shah SJ, Nakamura K, Marcus GM, et al. Association of the fourth
heart sound with increased left ventricular end-diastolic stiffness.
J Card Fail. 2008;14:431.

27. Shah SJ, Michaels AD. Hemodynamic correlates of the third heart
sound and systolic time intervals. Congest Heart Fail. 2006;12(4
suppl 1):8.

28. O’Rourke RA, Braunwald E. Ch 209, Physical examination of the
cardiovascular system. In Harrison’s Principles of Internal Medicine.
16th ed. New York: McGraw-Hill; 2005:1307.

29. Yancy CW, Jessup M, Bozkurt B, et al. 2013 AACF/AHA Guideline
for the Management of Heart Failure. J Am College Cardiol. 2013;
62:e148.

30. Vinayak AG, Levitt J, Gehlbach B, et al. Usefulness of the external
jugular vein examination in detecting abnormal central venous
pressure in critically ill patients Arch Int Med 2006;166:2132

xviii

xix

Contents

Faculty Reviewers vii
Preface ix
Acknowledgments xiii
How To Use Bates’ Guide To Physical

Examination And History Taking xv

UNIT 1
Foundations of Health Assessment 1

C H A P T E R 1
Foundations for Clinical Proficiency 3

PATIENT ASSESSMENT: COMPREHENSIVE
OR FOCUSED 5

Determining the Scope of Your Assessment 5
Subjective Versus Objective Data 6

THE COMPREHENSIVE ADULT HEALTH HISTORY 7

The Comprehensive Adult Health
History—Further Description 8

THE COMPREHENSIVE PHYSICAL
EXAMINATION 14

Beginning the Examination: Setting the Stage 14
The Physical Examination—“Head to Toe” 21

CLINICAL REASONING, ASSESSMENT,
AND PLAN 24

Clinical Reasoning and Assessment 25
Using Shared Decision-Making to Develop a Plan 29

THE QUALITY CLINICAL RECORD:
THE CASE OF MRS. N. 29

The Importance of the Problem List 37

RECORDING YOUR FINDINGS 38

References 42

C H A P T E R 2
Evaluating Clinical Evidence 45

THE HISTORY AND PHYSICAL EXAMINATION
AS DIAGNOSTIC TESTS 46

EVALUATING DIAGNOSTIC TESTS 47

Validity 47
Reproducibility 53

HEALTH PROMOTION 55

CRITICAL APPRAISAL 56

Understanding Bias 56
Results 57
Generalizability 59
Guideline Recommendations 59

LOOKING AHEAD 60

References 64

C H A P T E R 3
Interviewing and the Health History 65

DIFFERENT KINDS OF HEALTH HISTORIES 67

THE FUNDAMENTALS OF SKILLED
INTERVIEWING 68

THE SEQUENCE AND CONTEXT OF THE
INTERVIEW 73

Preparation 74
The Sequence of the Interview 75
The Cultural Context of the Interview 82

ADVANCED INTERVIEWING 86

Interviewing the Challenging Patient 86
Sensitive Topics 93

ETHICS AND PROFESSIONALISM 100

References 106

xx Contents

UNIT 2
Regional Examinations 109

C H A P T E R 4
Beginning the Physical Examination: General
Survey, Vital Signs, and Pain 111

THE HEALTH HISTORY 112

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 114

THE GENERAL SURVEY 120

General Appearance 120

THE VITAL SIGNS 123

Blood Pressure 124
Special Situations 131
Heart Rate and Rhythm 132
Respiratory Rate and Rhythm 132
Temperature 133

ACUTE AND CHRONIC PAIN 134

Assessing Acute and Chronic Pain 134

RECORDING YOUR FINDINGS 138

References 144

C H A P T E R 5
Behavior and Mental Status 147

SYMPTOMS AND BEHAVIOR 148

Understanding Symptoms: What Do They Mean? 148
Mental Health Screening 150

THE HEALTH HISTORY 153

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 156

TECHNIQUES OF EXAMINATION 158

Appearance and Behavior 158
Speech and Language 160
Mood 161
Thought and Perceptions 161
Cognitive Functions 164
Higher Cognitive Functions 165
Special Techniques 167

RECORDING YOUR FINDINGS 168

References 170

C H A P T E R 6
The Skin, Hair, and Nails 173

ANATOMY AND PHYSIOLOGY 173

Skin 173
Hair 174
Nails 175
Sebaceous Glands and Sweat Glands 175

THE HEALTH HISTORY 175

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 176

TECHNIQUES OF EXAMINATION 180

Full-Body and Integrated Skin Examinations 180
Preparing for the Examination 181
The Skin Examination 182
Special Techniques 187

RECORDING YOUR FINDINGS 189

References 214

C H A P T E R 7
The Head and Neck 215

THE HEALTH HISTORY 215

The Head 216
The Eyes 217
The Ears 219
The Nose and Sinuses 220
The Mouth, Throat, and Neck 221

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 222

ANATOMY AND PHYSIOLOGY AND
TECHNIQUES OF EXAMINATION 224

The Head 224
The Eyes 226
The Ear 242
The Nose and Paranasal Sinuses 248
Mouth and Pharynx 252
The Neck 257
Special Techniques 264

RECORDING YOUR FINDINGS 266

References 300

C H A P T E R 8
The Thorax and Lungs 303

ANATOMY AND PHYSIOLOGY 303

Locating Findings on the Chest 304

C o n t e n t s xxi

THE HEALTH HISTORY 310

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 313

TECHNIQUES OF EXAMINATION 317

Initial Survey of Respiration and the Thorax 318
Examination of the Posterior Chest 319
Examination of the Anterior Chest 327
Special Techniques 329

RECORDING YOUR FINDINGS 329

References 341

C H A P T E R 9
The Cardiovascular System 343

ANATOMY AND PHYSIOLOGY 343

Surface Projections of the Heart and Great Vessels 343
Cardiac Chambers, Valves, and Circulation 345
Events in the Cardiac Cycle 345
The Splitting of Heart Sounds 348
Heart Murmurs 349
Relation of Auscultatory Findings to the
Chest Wall 350
The Conduction System 351
The Heart as a Pump 352
Arterial Pulses and Blood Pressure 353
Jugular Venous Pressure and Pulsations 354
Changes Over the Life Span 355

THE HEALTH HISTORY 355

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 358

TECHNIQUES OF EXAMINATION 373

Blood Pressure and Heart Rate 373

Jugular Venous Pressure and Pulsations 374

The Carotid Pulse 380

The Heart 382

Inspection 384
Palpation 384

Percussion 389

Auscultation 389

Integrating Cardiovascular Assessment 397
Special Techniques: Maneuvers to Identify
Murmurs and Heart Failure 397

RECORDING YOUR FINDINGS 399

References 413

C H A P T E R 10
The Breasts and Axillae 419

ANATOMY AND PHYSIOLOGY 419

The Female Breast 419
The Male Breast 421
Lymphatics 421

THE HEALTH HISTORY 422

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 423

TECHNIQUES OF EXAMINATION 434

The Female Breast 434
The Male Breast 440
The Axillae 440
Special Techniques 441

RECORDING YOUR FINDINGS 443

References 446

C H A P T E R 11
The Abdomen 449

ANATOMY AND PHYSIOLOGY 449

THE HEALTH HISTORY 453

Patterns and Mechanisms of Abdominal Pain 453
The Gastrointestinal Tract 455
The Urinary Tract 462

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 464

TECHNIQUES OF EXAMINATION 470

The Abdomen 471
The Liver 475
The Spleen 479
The Kidneys 481
The Bladder 483
The Aorta 483
Special Techniques 484

RECORDING YOUR FINDINGS 487

References 505

C H A P T E R 12
The Peripheral Vascular System 509

ANATOMY AND PHYSIOLOGY 510

Arteries 510
Veins 513

xxii Contents

The Lymphatic System 515
Transcapillary Fluid Exchange 516

THE HEALTH HISTORY 517

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 519

TECHNIQUES OF EXAMINATION 521

Arms 522
Abdomen 524
Legs 524
Special Techniques 529

RECORDING YOUR FINDINGS 532

References 539

C H A P T E R 13
Male Genitalia and Hernias 541

ANATOMY AND PHYSIOLOGY 541

Lymphatics 543
Anatomy of the Groin 543

THE HEALTH HISTORY 544

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 547

TECHNIQUES OF EXAMINATION 550

The Penis 551
The Scrotum and its Contents 552
Hernias 553
Special Techniques 555

RECORDING YOUR FINDINGS 556

References 562

C H A P T E R 14
Female Genitalia 565

ANATOMY AND PHYSIOLOGY 565

THE HEALTH HISTORY 569

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 575

TECHNIQUES OF EXAMINATION 583

External Examination 586
Internal Examination 587
Hernias 594
Special Techniques 594

RECORDING YOUR FINDINGS 595

References 604

C H A P T E R 15
The Anus, Rectum, and Prostate 607

ANATOMY AND PHYSIOLOGY 607

THE HEALTH HISTORY 609

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 610

TECHNIQUES OF EXAMINATION 616

The Male Patient 616
The Female Patient 619

RECORDING YOUR FINDINGS 619

References 624

C H A P T E R 16
The Musculoskeletal System 625

APPROACH TO MUSCULOSKELETAL
DISORDERS 626

Types of Joints 628
Synovial Joints and Bursae 629

THE HEALTH HISTORY 630

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 636

EXAMINATION OF SPECIFIC JOINTS:
ANATOMY AND PHYSIOLOGY AND
TECHNIQUES OF EXAMINATION 642

Temporomandibular Joint 644
The Shoulder 645
The Elbow 656
The Wrist and Hands 657
The Spine 666
The Hip 674
The Knee 682
The Ankle and Foot 690
Special Techniques 694

RECORDING YOUR FINDINGS 695

References 708

C H A P T E R 17
The Nervous System 711

THE CHALLENGES OF NEUROLOGIC
DIAGNOSIS 712

ANATOMY AND PHYSIOLOGY 713

Central Nervous System 713

C o n t e n t s xxiii

Peripheral Nervous System 714
Motor Pathways 717
Sensory Pathways 719
Spinal Reflexes: The Muscle Stretch Response 720

THE HEALTH HISTORY 721

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 726

TECHNIQUES OF EXAMINATION 733

The Cranial Nerves 735
The Motor System 741
The Sensory System 752
Muscle Stretch Reflexes 758
Cutaneous or Superficial Stimulation Reflexes 763
Special Techniques 764

RECORDING YOUR FINDINGS 773

References 794

UNIT3
Special Populations 797

C H A P T E R 18
Assessing Children: Infancy through
Adolescence 799

GENERAL PRINCIPLES OF CHILD
DEVELOPMENT 800

HEALTH PROMOTION AND COUNSELING:
KEY COMPONENTS 801

Assessing the Newborn 803

Immediate Assessment at Birth 804
Assessment Several Hours After Birth 808

Assessing the Infant 809

Development 809
General Guidelines 810

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 812

TECHNIQUES OF EXAMINATION 813

General Survey and Vital Signs 813
The Skin 816
The Head 820
The Eyes 823
The Ears 825
The Nose and Sinuses 826
The Mouth and Pharynx 826

The Neck 828
The Thorax and Lungs 829
The Heart 832
The Breasts 838
The Abdomen 838
Male Genitalia 840
Female Genitalia 841
Rectal Examination 842
The Musculoskeletal System 842
The Nervous System 845

Assessing Young and School-Aged Children 853

Development 853

THE HEALTH HISTORY 855

Assessing Younger Children 855
Assessing Older Children 857

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 860

Children 1 to 4 Years 860
Children 5 to 10 Years 861

TECHNIQUES OF EXAMINATION 862

General Survey and Vital Signs 862
The Skin 865
The Head 865
The Eyes 866
The Ears 867
The Nose and Sinuses 871
The Mouth and Pharynx 872
The Neck 875
The Thorax and Lungs 876
The Heart 877
The Abdomen 879
Male Genitalia 881
Female Genitalia 882
The Rectal Examination 885
The Musculoskeletal System 885
The Nervous System 887

Assessing Adolescents 890

Development: 11 to 20 Years 890

THE HEALTH HISTORY 891

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 893

TECHNIQUES OF EXAMINATION 894

General Survey and Vital Signs 894
The Skin 895
Head, Ears, Eyes, Throat, and Neck 895
The Heart 895
The Breasts 896
The Abdomen 898
Male Genitalia 898

xxiv Contents

Female Genitalia 900
The Musculoskeletal System 901
The Nervous System 906

RECORDING YOUR FINDINGS 906

References 924

C H A P T E R 19
The Pregnant Woman 927

ANATOMY AND PHYSIOLOGY 927

Physiologic Hormonal Changes 927
Anatomic Changes 928

THE HEALTH HISTORY 932

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 935

TECHNIQUES OF EXAMINATION 940

Positioning 940
Examining Equipment 941
General Inspection 941
Height, Weight, and Vital Signs 942
Head and Neck 942
Thorax and Lungs 943
Heart 943
Breasts 943
Abdomen 944
Genitalia 945

Anus 947
Rectum and Rectovaginal Septum 947
Extremities 948
Special Techniques 948

RECORDING YOUR FINDINGS 951

References 953

C H A P T E R 20
The Older Adult 955

ANATOMY AND PHYSIOLOGY 957

THE HEALTH HISTORY 965

Approach to the Patient 965

Special Areas of Concern When Assessing
Common Symptoms 970

HEALTH PROMOTION AND COUNSELING:
EVIDENCE AND RECOMMENDATIONS 976

TECHNIQUES OF EXAMINATION 985

Assessing Functional Status: the “Sixth Vital Sign” 985
Physical Examination of the Older Adult 989

RECORDING YOUR FINDINGS 998

References 1004

Index 1009

xxv

List of Tables

C H A P T E R 1 Foundations for Clinical Proficiency 3
Table 1-1: Sample Progress Note 41

C H A P T E R 2 Evaluating Clinical Evidence 45
Table 2-1: U.S. Preventive Service Task Force Ratings: Grade Definitions and

Implications for Practice 61
Table 2-2: U.S. Preventive Services Task Force Levels of Certainty Regarding Benefit 62
Table 2-3: American College of Chest Physicians: Grading Recommendations 63

C H A P T E R 3 Interviewing and the Health History 65
Table 3-1: Motivational Interviewing: A Clinical Example 104
Table 3-2: Brief Action Planning (BAP)—A Self-Management Support Tool 105

C H A P T E R 4 Beginning the Physical Examination: General Survey, Vital Signs,
and Pain 111

Table 4-1: Obesity-Related Health Conditions 139
Table 4-2: Eating Disorders and Excessively Low BMI 140
Table 4-3: Nutrition Screening 141
Table 4-4: Obesity: Stages of Change Model and Assessing Readiness 142
Table 4-5: Nutrition Counseling: Sources of Nutrients 143
Table 4-6: Patients with Hypertension: Recommended Changes in Diet 143

C H A P T E R 5 Behavior and Mental Status 147
Table 5-1: Somatic Symptom and Related Disorders 169

C H A P T E R 6 The Skin, Hair, and Nails 173
Table 6-1: Describing Primary Skin Lesions: Flat, Raised, and Fluid-Filled 191
Table 6-2: Additional Primary Lesions: Pustules, Furuncles, Nodules, Cysts,

Wheals, Burrows 194
Table 6-3: Dermatology Safari: Benign Lesions 196
Table 6-4: Rough Lesions: Actinic Keratoses, Squamous Cell Carcinoma, and

Their Mimics 197
Table 6-5: Pink Lesions: Basal Cell Carcinoma and Its Mimics 198
Table 6-6: Brown Lesions: Melanoma and Its Mimics 200
Table 6-7: Acne Vulgaris—Primary and Secondary Lesions 204
Table 6-8: Vascular and Purpuric Lesions of the Skin 205
Table 6-9: Signs of Sun Damage 206
Table 6-10: Systemic Diseases and Associated Skin Findings 207
Table 6-11: Hair Loss 209
Table 6-12: Findings in or Near the Nails 211
Table 6-13: Pressure Ulcers 213

xxvi List of Tables

C H A P T E R 7 The Head and Neck 215
Table 7-1: Primary Headaches 267
Table 7-2: Secondary Headaches and Cranial Neuralgias 268
Table 7-3: Red Eyes 270
Table 7-4: Dizziness and Vertigo 271
Table 7-5: Selected Facies 272
Table 7-6: Visual Field Defects 273
Table 7-7: Variations and Abnormalities of the Eyelids 274
Table 7-8: Lumps and Swellings in and Around the Eyes 275
Table 7-9: Opacities of the Cornea and Lens 276
Table 7-10: Pupillary Abnormalities 277
Table 7-11: Dysconjugate Gaze 278
Table 7-12: Normal Variations of the Optic Disc 279
Table 7-13: Abnormalities of the Optic Disc 280
Table 7-14: Retinal Arteries and Arteriovenous Crossings: Normal and Hypertensive 281
Table 7-15: Red Spots and Streaks in the Fundi 282
Table 7-16: Ocular Fundi: Normal and Hypertensive Retinopathy 283
Table 7-17: Ocular Fundi: Diabetic Retinopathy 284
Table 7-18: Light-Colored Spots in the Fundi 285
Table 7-19: Lumps on or Near the Ear 286
Table 7-20: Abnormalities of the Eardrum 287
Table 7-21: Patterns of Hearing Loss 289
Table 7-22: Abnormalities of the Lips 290
Table 7-23: Findings in the Pharynx, Palate, and Oral Mucosa 292
Table 7-24: Findings in the Gums and Teeth 295
Table 7-25: Findings in or Under the Tongue 297
Table 7-26: Thyroid Enlargement and Function 299
Table 7-27: Symptoms and Signs of Thyroid Dysfunction 299

C H A P T E R 8 The Thorax and Lungs 303
Table 8-1: Chest Pain 330
Table 8-2: Dyspnea 332
Table 8-3: Cough and Hemoptysis 334
Table 8-4: Abnormalities in Rate and Rhythm of Breathing 335
Table 8-5: Deformities of the Thorax 336
Table 8-6: Normal and Altered Breath and Voice Sounds 337
Table 8-7: Adventitious (Added) Lung Sounds: Causes and Qualities 338
Table 8-8: Physical Findings in Selected Chest Disorders 339

C H A P T E R 9 The Cardiovascular System 343
Table 9-1: Selected Heart Rates and Rhythms 400
Table 9-2: Selected Irregular Rhythms 401
Table 9-3: Abnormalities of the Arterial Pulse and Pressure Waves 402
Table 9-4: Variations and Abnormalities of the Ventricular Impulses 403
Table 9-5: Variations in the First Heart Sound—S1 404
Table 9-6: Variations in the Second Heart Sound—S2 405
Table 9-7: Extra Heart Sounds in Systole 406
Table 9-8: Extra Heart Sounds in Diastole 407
Table 9-9: Midsystolic Murmurs 408
Table 9-10: Pansystolic (Holosystolic) Murmurs 410

L i s t o f T a b l e s xxvii

Table 9-11: Diastolic Murmurs 411
Table 9-12: Cardiovascular Sounds with Both Systolic and Diastolic Components 412

C H A P T E R 10 The Breasts and Axillae 419
Table 10-1: Common Breast Masses 444
Table 10-2: Visible Signs of Breast Cancer 445

C H A P T E R 11 The Abdomen 449
Table 11-1: Abdominal Pain 488
Table 11-2: Dysphagia 490
Table 11-3: Diarrhea 491
Table 11-4: Constipation 494
Table 11-5: Black and Bloody Stool 495
Table 11-6: Urinary Frequency, Nocturia, and Polyuria 496
Table 11-7: Urinary Incontinence 497
Table 11-8: Localized Bulges in the Abdominal Wall 499
Table 11-9: Protuberant Abdomens 500
Table 11-10: Sounds in the Abdomen 501
Table 11-11: Tender Abdomens 502
Table 11-12: Liver Enlargement: Apparent and Real 504

C H A P T E R 12 The Peripheral Vascular System 509
Table 12-1: Types of Peripheral Edema 533
Table 12-2: Painful Peripheral Vascular Disorders and Their Mimics 534
Table 12-3: Using the Ankle–Brachial Index 536
Table 12-4: Chronic Insufficiency of Arteries and Veins 537
Table 12-5: Common Ulcers of the Ankles and Feet 538

C H A P T E R 13 Male Genitalia and Hernias 541
Table 13-1: Sexually Transmitted Infections of Male Genitalia 557
Table 13-2: Abnormalities of the Penis and Scrotum 558
Table 13-3: Abnormalities of the Testis 559
Table 13-4: Abnormalities of the Epididymis and Spermatic Cord 560
Table 13-5: Course, Presentation, and Differentiation of Hernias in the Groin 561

C H A P T E R 14 Female Genitalia 565
Table 14-1: Lesions of the Vulva 596
Table 14-2: Bulges and Swelling of the Vulva, Vagina, and Urethra 597
Table 14-3: Vaginal Discharge 598
Table 14-4: Variations in the Cervical Surface 599
Table 14-5: Shapes of the Cervical Os 600
Table 14-6: Abnormalities of the Cervix 600
Table 14-7: Positions of the Uterus 601
Table 14-8: Abnormalities of the Uterus 602
Table 14-9: Adnexal Masses 603

C H A P T E R 15 The Anus, Rectum, and Prostate 607
Table 15-1: BPH Symptom Score: American Urological Association 620
Table 15-2: Abnormalities of the Anus, Surrounding Skin, and Rectum 621
Table 15-3: Abnormalities of the Prostate 623

xxviii List of Tables

C H A P T E R 16 The Musculoskeletal System 625
Table 16-1: Patterns of Pain in and Around the Joints 696
Table 16-2: Pains in the Neck 698
Table 16-3: Low Back Pain 699
Table 16-4: Painful Shoulders 700
Table 16-5: Swollen or Tender Elbows 702
Table 16-6: Arthritis in the Hands 703
Table 16-7: Swellings and Deformities of the Hands 704
Table 16-8: Tendon Sheath, Palmar Space, and Finger Infections 705
Table 16-9: Abnormalities of the Feet 706
Table 16-10: Abnormalities of the Toes and Soles 707

C H A P T E R 17 The Nervous System 711
Table 17-1: Disorders of the Central and Peripheral Nervous Systems 774
Table 17-2: Types of Stroke 776
Table 17-3: Syncope and Similar Disorders Problem 778
Table 17-4: Seizure Disorders 780
Table 17-5: Tremors and Involuntary Movements 782
Table 17-6: Disorders of Speech 784
Table 17-7: Nystagmus 785
Table 17-8: Types of Facial Paralysis 787
Table 17-9: Disorders of Muscle Tone 788
Table 17-10: Abnormalities of Gait and Posture 789
Table 17-11: Metabolic and Structural Coma 790
Table 17-12: Glasgow Coma Scale 791
Table 17-13: Pupils in Comatose Patients 792
Table 17-14: Abnormal Postures in Comatose Patients 793

C H A P T E R 18 Assessing Children: Infancy through Adolescence 799
Table 18-1: Abnormalities in Heart Rhythm and Blood Pressure 910
Table 18-2: Common Skin Rashes and Skin Findings in Newborns and Infants 911
Table 18-3: Warts, Lesions That Resemble Warts, and Other Raised Lesions 912
Table 18-4: Common Skin Lesions During Childhood 912
Table 18-5: Abnormalities of the Head 913
Table 18-6: Diagnostic Facies in Infancy and Childhood 914
Table 18-7: Abnormalities of the Eyes, Ears, and Mouth 916
Table 18-8: Abnormalities of the Teeth, Pharynx, and Neck 917
Table 18-9: Cyanosis in Children 918
Table 18-10: Congenital Heart Murmurs 919
Table 18-11: Physical Signs of Sexual Abuse 921
Table 18-12: The Male Genitourinary System 922
Table 18-13: Common Musculoskeletal Findings in Young Children 922
Table 18-14: The Power of Prevention: Vaccine-Preventable Diseases 923

C H A P T E R 20 The Older Adult 955
Table 20-1: Interviewing Older Adults: Enhancing Culturally Appropriate Care 1000
Table 20-2: Delirium and Dementia 1001
Table 20-3: Screening for Dementia: The Mini-Cog 1002
Table 20-4: Screening for Dementia: The Montreal Cognitive Assessment (MoCA) 1003

UNIT

Foundations of Health
Assessment 1

C h a p t e r 1

Foundations for Clinical

Proficiency 3

C h a p t e r 2

Evaluating Clinical Evidence 45

C h a p t e r 3

Interviewing and the Health

History 65

C H A P T E R 1 |

Foundations for Clinical Proficiency 3

The techniques of physical examination and history taking that you are about to
learn embody the time-honored skills of healing and patient care. Gathering a
sensitive and nuanced history and performing a thorough and accurate examina-
tion deepen your relationships with patients, focus your assessment, and set the
guideposts that direct your clinical decision making (Fig. 1-1). The quality of
your history and physical examination lays the foundation for patient assess-
ment, your recommendations for care, and your choices for further evaluation
and testing. As you become an accomplished clinician, you will continually pol-
ish these important relational and clinical skills.

With practice, you will meet the challenge of integrating the essential ele-
ments of clinical care: empathic listening; the ability to interview patients of
all ages, moods, and backgrounds; the techniques for examining the different
body systems; levels of illness; and, finally, the process of clinical reasoning
leading to your diagnosis and plan. Your experience with history taking and
physical examination will grow, and will trigger the steps of clinical reasoning
from the first moments of the patient encounter: identifying symptoms and
abnormal findings; linking findings to underlying pathophysiology or psy-
chopathology; and establishing and testing a set of explanatory hypotheses.
Working through these steps will reveal the multifaceted profile of the patient
before you. Paradoxically, the skills that allow you to assess all patients also
shape the clinical portrait of the unique human being entrusted to your care.
The physical examination is more than a means of gathering data and generat-
ing hypotheses for causality and testing. It is vital to the “formation of the
[clinician]–patient bond, the beginning of a therapeutic partnership and the
healing process (Fig. 1-2).”1

This chapter, revised in this edition, provides a guide to clinical proficiency
in four critical areas: the Health History; the Physical Examination; Clinical

C H A P T E R

1
Foundations for
Clinical Proficiency

The Bates’ suite offers these additional resources to enhance learning and facilitate
understanding of this chapter:
■ Bates’ Pocket Guide to Physical Examination and History Taking, 8th edition
■ Bates’ Visual Guide to Physical Examination (All Volumes)
â–  thePoint online resources, for students and instructors: http://thepoint.lww.com

F I G U R E 1 – 1 . The importance of

establishing rapport.

F I G U R E 1 – 2 . The skilled physical

examination.

4 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

FOUNDATIONS FOR CLINICAL PROFICIENCY

Reasoning, Assessment, and Plan; and The Quality Clinical Record. It describes
the components of the health history and how to organize the patient’s story;
and it gives an overview of the physical examination with a sequence for
ensuring patient comfort that briefly describes techniques of examination for
each component of the physical examination, from the General Survey
through the Nervous System. In this edition, the chapter also includes Clini-
cal Reasoning, Assessment, and Plan, and The Quality Clinical Record. The new
Chapter 2, Evaluating Clinical Evidence, provides the analytic tools for eval-
uating tests, guidelines, and the clinical literature that will ensure best prac-
tices and lifelong clinical learning. Chapter 3, Interviewing and the Health
History, completes the foundational chapters that prepare you for performing
the physical examination. You will learn the techniques of physical examina-
tion in Chapters 4 through 17. Each chapter is evidence based and includes
citations from the clinical literature for easy reference so that you can con-
tinue to expand your knowledge. Beginning with Chapter 4, sections on
Health Promotion and Counseling: Evidence and Recommendations review cur-
rent clinical guidelines for preventive care.

The Bates’ Guide to Physical Examination and History Taking follows the
sequence described below:

â–  Chapter 2, Evaluating Clinical Evidence, discusses the history and physical
examination as diagnostic tools, evaluation of the validity and reproducibil-
ity of diagnostic tests, health promotion, critical appraisal of the clinical
research, and grading criteria for clinical guidelines.

â–  Chapter 3, Interviewing and the Health History, expands on the essential,
varied, and often complex skills of building patient rapport and eliciting
the patient’s story. It addresses basic and advanced interviewing techniques
and the approach to challenging patients as well as cultural competence
and professionalism.

â–  Chapters 4 to 17 are regional examination chapters, which detail the pertinent
anatomy and physiology, health history, evidence-based guidelines for health
promotion and counseling, techniques of examination, and the written re-
cord, followed by tables comparing common symptoms and physical find-
ings and citations from the literature.

â–  Chapters 18 to 20 extend and adapt the elements of the adult history and
physical examination to special populations: newborns, infants, children,
and adolescents; pregnant women; and older adults.

As you acquire the skills of physical examination and history taking, you will
move to active patient assessment, gradually at first, but then with growing con-
fidence and expertise, and ultimately clinical competence. From mastery of these
skills and the mutual trust and respect of caring patient relationships emerge the
timeless rewards of the clinical professions.

C H A P T E R 1 |

Foundations for Clinical Proficiency 5

PATIENT ASSESSMENT: COMPREHENSIVE OR FOCUSED

Determining the Scope of Your Assessment

At the outset of each patient encounter, you will face the common questions,
“How much should I do?” and “Should my assessment be comprehensive or
focused?” For patients you are seeing for the first time in the office or hospital,
you will usually choose to conduct a comprehensive assessment, which includes
all the elements of the health history and the complete physical examination. In
many situations, a more flexible focused or problem-oriented assessment is appro-
priate, particularly for patients you know well returning for routine care, or those
with specific “urgent care” concerns like sore throat or knee pain. You will adjust
the scope of your history and physical examination to the situation at hand,
keeping several factors in mind: the magnitude and severity of the patient’s prob-
lems; the need for thoroughness; the clinical setting—inpatient or outpatient,
primary or subspecialty care; and the time available. Skill in all the components
of a comprehensive assessment allows you to select the elements that are most
pertinent to the patient’s concerns, yet meet clinical standards for best practice
and diagnostic accuracy.

As you can see, the comprehensive examination does more than assess body sys-
tems. It is a source of fundamental and personalized knowledge about the patient
that strengthens the clinician–patient relationship. Most people seeking care have
specific worries or symptoms. The comprehensive examination provides a more
complete basis for assessing these concerns and answering patient questions.

The History and Physical Examination:
Comprehensive or Focused?

Comprehensive Assessment Focused Assessment

Is appropriate for new patients in the

office or hospital

Provides fundamental and personal-

ized knowledge about the patient

Strengthens the clinician–patient

relationship

Helps identify or rule out physical

causes related to patient concerns

Provides a baseline for future assess-

ments

Creates a platform for health promotion

through education and counseling

Develops proficiency in the essential

skills of physical examination

Is appropriate for established patients,

especially during routine or urgent

care visits

Addresses focused concerns or symp-

toms

Assesses symptoms restricted to a

specific body system

Applies examination methods rele-

vant to assessing the concern or

problem as thoroughly and care-

fully as possible

Patient Assessment:
Comprehensive or Focused

6 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

PATIENT ASSESSMENT: COMPREHENSIVE OR FOCUSED

For the focused examination, you will select the methods relevant to thorough
assessment of the targeted problem. The patient’s symptoms, age, and health
history help determine the scope of the focused examination, as does your
knowledge of disease patterns. Of all the patients with sore throat, for example,
you will need to decide who may have infectious mononucleosis and warrants
careful palpation of the liver and spleen and who, by contrast, has a common
cold amenable to a more focused examination of the head, neck, and lungs. The
clinical reasoning that underlies and guides such decisions is discussed later in
this chapter.

What about the routine clinical check-up, or periodic health examination? Numerous
studies have scrutinized the usefulness of the annual well-patient visit for screen-
ing and prevention of illness, in contrast to evaluation of symptoms, without
coming to a clear consensus.2–10 A growing body of evidence documents the
utility of many components of the physical examination, its vital role in decision
making, and its potential for savings through decreased testing.11–15 Validated
examination techniques include blood pressure measurement, assessment of
central venous pressure from the jugular venous pulse, listening to the heart for
evidence of valvular disease, detection of hepatic and splenic enlargement, and
the pelvic examination with Papanicolaou (Pap) smears. Various consensus pan-
els and expert advisory groups have further expanded recommendations for
examination and screening, which will be addressed in the regional examination
chapters.

What about the newer evidence about the physical examination itself and its
relationship to advanced diagnostic testing? Recent studies view the physical
examination findings themselves as diagnostic tests and have begun to validate
their value by identifying their test characteristics using Bayes’ theorem and
the evidence-based tools described in Chapter 2, Evaluating Clinical
Evidence.16,17 Over time, “the rational clinical examination” is expected to
improve diagnostic decision making, especially as national competencies and
best teaching practices for physical examination skills become better under-
stood.11,18 Meanwhile, the physical examination yields “the intangible benefits
of more time spent … communicating with patients,”18 a unique therapeutic
relationship, more accurate diagnoses, and more selective assessments and
plans of care.1,11

Subjective Versus Objective Data

As you acquire the techniques of history taking and physical examination,
remember the important differences between subjective information and objective
information, summarized in the table below. Symptoms are subjective concerns,
or what the patient tells you. Signs are considered one type of objective informa-
tion, or what you observe. Knowing these differences helps you group together
the different types of patient information. These distinctions are equally impor-
tant for organizing written and oral presentations about patients into a logical
and understandable format.

C H A P T E R 1 |

Foundations for Clinical Proficiency 7

THE COMPREHENSIVE ADULT HEALTH HISTORY

See Chapter 18, Assessing Children:

Infancy Through Adolescence, for the

comprehensive history and examina-

tion of infants, children, and adoles-

cents, pp. 799–925.

Components of the Comprehensive
Health History

● Identifying data and source of the history; reliability
● Chief complaint(s)
● Present illness
● Past history
● Family history
● Personal and social history
● Review of systems

As you will learn in Chapter 3, Interviewing and the Health History, when you
talk with patients, the health history rarely emerges in this order. The interview
is more fluid; you will closely follow the patient’s cues to elicit the patient’s nar-
rative of illness, provide empathy, and strengthen rapport. You will quickly learn
where to fit different aspects of the patient’s story into the more formal format of
the oral presentation and written record. You will transform the patient’s lan-
guage and story into the components of the health history familiar to all mem-
bers of the health care team. This restructuring organizes your clinical reasoning
and provides a template for your expanding clinical expertise.

As you begin your clinical journey, review the components of the adult health
history, then study the more detailed explanations that follow.

Differences Between Subjective and
Objective Data

Subjective Data Objective Data

What the patient tells you What you detect during the examination,

laboratory information, and test data

The symptoms and history, from
Chief Complaint through

Review of Systems

All physical examination findings, or signs

Example: Mrs. G. is a 54-year-old
hairdresser who reports pressure

over her left chest “like an ele-

phant sitting there,” which goes

into her left neck and arm.

Example: Mrs. G. is an older, overweight
white female, who is pleasant and coop-

erative. Height 5′4″, weight 150 lbs, BMI
26, BP 160/80, HR 96 and regular, respi-

ratory rate 24, temperature 97.5 °F

The Comprehensive Adult
Health History

8 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE COMPREHENSIVE ADULT HEALTH HISTORY

Overview: Components of the Adult
Health History

Identifying Data Identifying data—such as age, gender, occupation,
marital status

Source of the history—usually the patient, but can be
a family member or friend, letter of referral, or the

clinical record

If appropriate, establish the source of referral, because a
written report may be needed

Reliability Varies according to the patient’s memory, trust, and
mood

Chief
Complaint(s)

The one or more symptoms or concerns causing the

patient to seek care

Present Illness Amplifies the Chief Complaint; describes how each
symptom developed

Includes patient’s thoughts and feelings about the illness

Pulls in relevant portions of the Review of Systems, called
“pertinent positives and negatives” (see p. 11)

May include medications, allergies, and tobacco use and
alcohol, which are frequently pertinent to the present
illness

Past History Lists childhood illnesses
Lists adult illnesses with dates for events in at least four

categories: medical, surgical, obstetric/gynecologic,

and psychiatric

Includes health maintenance practices such as immuni-

zations, screening tests, lifestyle issues, and home

safety

Family History Outlines or diagrams age and health, or age and cause of
death, of siblings, parents, and grandparents

Documents presence or absence of specific illnesses in

family, such as hypertension, diabetes, or type of

cancer

Personal and
Social History

Describes educational level, family of origin, current

household, personal interests, and lifestyle

Review of
Systems

Documents presence or absence of common symptoms

related to each of the major body systems

The Comprehensive Adult Health
History—Further Description

Initial Information

Date and Time of History. The date is always important. Be sure to docu-
ment the time you evaluate the patient, especially in urgent, emergent, or hospital
settings.

C H A P T E R 1 |

Foundations for Clinical Proficiency 9

THE COMPREHENSIVE ADULT HEALTH HISTORY

Identifying Data. These include age, gender, marital status, and occupa-
tion. The source of history or referral can be the patient, a family member or
friend, an officer, a consultant, or the clinical record. Identifying the source of
referral helps you assess the quality of the referral information, questions you may
need to address in your assessment and written response.

Reliability. Document this information, if relevant. This judgment
reflects the quality of the information provided by the patient and is usually
made at the end of the interview. For example, “The patient is vague when
describing symptoms, and the details are confusing,” or, “The patient is a reli-
able historian.”

Chief Complaint(s). Make every attempt to quote the patient’s own words.
For example, “My stomach hurts and I feel awful.” If patients have no specific
complaints, report their reason for the visit, such as “I have come for my regular
check-up” or “I’ve been admitted for a thorough evaluation of my heart.”

Present Illness. This Present Illness is a complete, clear, and chronologic
description of the problems prompting the patient’s visit, including the onset of
the problem, the setting in which it developed, its manifestations, and any treat-
ments to date.

â–  Each principal symptom should be well characterized, and should include
the seven attributes of a symptom: (1) location; (2) quality; (3) quantity or
severity; (4) timing, including onset, duration, and frequency; (5) the setting
in which it occurs; (6) factors that have aggravated or relieved the symptom;
and (7) associated manifestations. It is also important to query the “perti-
nent positives” and “pertinent negatives” drawn from sections of the Review
of Systems that are relevant to the Chief Complaint(s). The presence or
absence of these additional symptoms helps you generate the differential
diagnosis, which includes the most likely and, at times, the most serious
diagnoses, even if less likely, which could explain the patient’s condition.

â–  Other information is frequently relevant, such as risk factors for coronary
artery disease in patients with chest pain, or current medications in patients
with syncope.

■ The Present Illness should reveal the patient’s responses to his or her symp-
toms and what effect the illness has had on the patient’s life. Always remem-
ber, the data flow spontaneously from the patient, but the task of oral and written
organization is yours.

â–  Patients often have more than one symptom or concern. Each symptom mer-
its its own paragraph and a full description.

â–  Medications should be noted, including name, dose, route, and frequency
of use. Also, list home remedies, nonprescription drugs, vitamins, mineral
or herbal supplements, oral contraceptives, and medicines borrowed from
family members or friends. Ask patients to bring in all their medications so
that you can see exactly what they take.

See discussion of the seven attributes

of a symptom in Chapter 3, Interview-

ing and the Health History,

pp. 65–108.

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THE COMPREHENSIVE ADULT HEALTH HISTORY

â–  Allergies, including specific reactions to each medication, such as rash or nau-
sea, must be recorded, as well as allergies to foods, insects, or environmental
factors.

â–  Note tobacco use, including the type. Cigarettes are often reported in pack-
years (a person who has smoked 1½ packs a day for 12 years has an 18-pack/
year history). If someone has quit, note for how long.

â–  Alcohol and drug use should always be investigated and is often pertinent
to the Presenting Illness.

Past History

â–  Childhood Illnesses: These include measles, rubella, mumps, whooping
cough, chickenpox, rheumatic fever, scarlet fever, and polio. Also included
are any chronic childhood illnesses.

â–  Adult Illnesses: Provide information relative to Adult Illnesses in each of the
four areas:

â–  Medical: Illnesses such as diabetes, hypertension, hepatitis, asthma, and
human immunodeficiency virus (HIV); hospitalizations; number and
gender of sexual partners; and risk-taking sexual practices

â–  Surgical: Dates, indications, and types of operations

â–  Obstetric/Gynecologic: Obstetric history, menstrual history, methods of
contraception, and sexual function

â–  Psychiatric: Illness and time frame, diagnoses, hospitalizations, and
treatments

â–  Health Maintenance: Cover selected aspects of Health Maintenance, espe-
cially immunizations and screening tests. For immunizations, find out
whether the patient has received vaccines for tetanus, pertussis, diphthe-
ria, polio, measles, rubella, mumps, influenza, varicella, hepatitis B virus
(HBV), human papilloma virus (HPV), meningococcal disease, Haemophilus
influenzae type B, pneumococci, and herpes zoster. For screening tests, re-
view tuberculin tests, Pap smears, mammograms, stool tests for occult
blood, colonoscopy and cholesterol tests, together with results and when
they were last performed. If the patient does not know this information,
written permission may be needed to obtain prior clinical records.

Family History. Under Family History, outline or diagram the age and health,
or age and cause of death, of each immediate relative including parents, grand-
parents, siblings, children, and grandchildren. Review each of the following con-
ditions and record whether they are present or absent in the family: hypertension,
coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or
renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure
disorder, mental illness, suicide, substance abuse, and allergies, as well as

See Chapter 3, Interviewing and

the Health History, for suggested

questions about alcohol and drug

use, pp. 65–108.

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THE COMPREHENSIVE ADULT HEALTH HISTORY

symptoms reported by the patient. Ask about any history of breast, ovarian,
colon, or prostate cancer. Ask about any genetically transmitted diseases.

Personal and Social History. The Personal and Social History captures the
patient’s personality and interests, sources of support, coping style, strengths,
and concerns. It should include occupation and the last year of schooling; home
situation and significant others; sources of stress, both recent and long-term;
important life experiences such as military service, job history, financial situa-
tion, and retirement; leisure activities; religious affiliation and spiritual beliefs;
and activities of daily living (ADLs). Baseline level of function is particularly
important in older or disabled patients. The Personal and Social History includes
lifestyle habits that promote health or create risk, such as exercise and diet, includ-
ing frequency of exercise, usual daily food intake, dietary supplements or restric-
tions, and use of coffee, tea, and other caffeinated beverages, and safety measures,
including use of seat belts, bicycle helmets, sunblock, smoke detectors, and
other devices related to specific hazards. Include sexual orientation and practices
and any alternative health care practices. Avoid restricting the Personal and Social
History to only tobacco, drug, and alcohol use. An expanded Personal and Social
History personalizes your relationship with the patient and builds rapport.

You will learn to intersperse personal and social questions throughout the inter-
view to make the patient feel more at ease.

Review of Systems

See pp. 970–971 for the ADLs fre-

quently assessed in older adults.

Tips for Eliciting the Review of Systems

● Understanding and using Review of Systems questions may seem challeng-
ing at first. These “yes-no” questions should come at the end of the inter-

view. Think about asking a series of questions going from “head to toe.”
It is helpful to prepare the patient by saying, “The next part of the history

may feel like a hundred questions, but it is important to make sure we

have not missed anything.” Most Review of Systems questions pertain to
symptoms, but on occasion, some clinicians include diseases like pneumo-

nia or tuberculosis.
● Note that as you elicit the Present Illness, you may also draw on Review of

Systems questions related to system(s) relevant to the Chief Complaint to
establish “pertinent positives and negatives” that help clarify the diagnosis.
For example, after a full description of chest pain, you may ask, “Do you have

any history of high blood pressure . . . palpitations . . . shortness of breath . . .

swelling in your ankles or feet?” or even move to questions from the Respira-
tory or Gastrointestinal Review of Systems.

See Chapter 3, Interviewing and the

Health History, for discussion of the

role of pertinent positives and nega-

tives in establishing the differential

diagnosis, p. 80.

Start with a fairly general question as you address each of the different systems,
then shift to more specific questions about systems that may be of concern.
Examples of starting questions are, “How are your ears and hearing?” “How
about your lungs and breathing?” “Any trouble with your heart?” “How is your
digestion?” “How about your bowels?” The need for additional questions will

12 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE COMPREHENSIVE ADULT HEALTH HISTORY

vary depending on the patient’s age, complaints, and general state of health and
your clinical judgment.

â–  The Review of Systems questions may uncover problems that the patient has
overlooked, particularly in areas unrelated to the Present Illness. Significant
health events, such as past surgery, hospitalization for a major prior illness, or
a parent’s death, require full exploration. Keep your technique flexible.
Remember that major health events discovered during the Review of Systems
should be moved to the Present Illness or Past History in your write-up.

â–  Some experienced clinicians do the Review of Systems during the physical
examination, asking about the ears, for example, as they examine them. If
the patient has only a few symptoms, this combination can be efficient. If
there are multiple symptoms, however, this can disrupt the flow of both the
history and the examination, and necessary note taking becomes awkward.

Listed below is a standard series of Review-of-System questions. As you gain expe-
rience, these “yes or no” questions will take no more than several minutes. For
each regional “system” ask: “Have you ever had any…?”

The Review of Systems

General: Usual weight, recent weight change, clothing that fits more tightly or
loosely than before; weakness, fatigue, or fever.

Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or
nails; changes in size or color of moles.

Head, Eyes, Ears, Nose, Throat (HEENT):
Head: Headache, head injury, dizziness, lightheadedness.

Eyes: Vision, glasses or contact lenses, last examination, pain, redness,

excessive tearing, double or blurred vision, spots, specks, flashing lights,

glaucoma, cataracts.

Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is

decreased, use or nonuse of hearing aids.

Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay

fever, nosebleeds, sinus trouble.

Throat (or mouth and pharynx): Condition of teeth and gums, bleeding gums,

dentures, if any, and how they fit, last dental examination, sore tongue, dry

mouth, frequent sore throats, hoarseness.

Neck: “Swollen glands,” goiter, lumps, pain, or stiffness in the neck.
Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination practices.
Respiratory: Cough, sputum (color, quantity; presence of blood or hemoptysis),

shortness of breath (dyspnea), wheezing, pain with a deep breath (pleuritic

pain), last chest x-ray. You may wish to include asthma, bronchitis, emphy-

sema, pneumonia, and tuberculosis.

Cardiovascular: “Heart trouble”; high blood pressure; rheumatic fever; heart mur-
murs; chest pain or discomfort; palpitations; shortness of breath; need to use

pillows at night to ease breathing (orthopnea); need to sit up at night to ease

(continued )

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THE COMPREHENSIVE ADULT HEALTH HISTORY

The Review of Systems (continued )

breathing (paroxysmal nocturnal dyspnea); swelling in the hands, ankles, or feet

(edema); results of past electrocardiograms or other cardiovascular tests.

Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea. Bowel move-
ments, stool color and size, change in bowel habits, pain with defecation,

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.

Peripheral vascular: Intermittent leg pain with exertion (claudication); leg
cramps; varicose veins; past clots in the veins; swelling in calves, legs, or feet;

color change in fingertips or toes during cold weather; swelling with redness

or tenderness.

Urinary: Frequency of urination, polyuria, nocturia, urgency, burning or pain
during urination, blood in the urine (hematuria), urinary infections, kidney or

flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in

males, reduced caliber or force of the urinary stream, hesitancy, dribbling.

Genital: Male: Hernias, discharge from or sores on the penis, testicular pain or
masses, scrotal pain or swelling, history of sexually transmitted infections and

their treatments. Sexual habits, interest, function, satisfaction, birth control

methods, condom use, and problems. Concerns about HIV infection. Female:
Age at menarche, regularity, frequency, and duration of periods, amount of

bleeding; bleeding between periods or after intercourse, last menstrual period,

dysmenorrhea, premenstrual tension. Age at menopause, menopausal symp-

toms, postmenopausal bleeding. If the patient was born before 1971, exposure to

diethylstilbestrol (DES) from maternal use during pregnancy (linked to cervical

carcinoma). Vaginal discharge, itching, sores, lumps, sexually transmitted infec-

tions and treatments. Number of pregnancies, number and type of deliveries,

number of abortions (spontaneous and induced), complications of pregnancy,

birth-control methods. Sexual preference, interest, function, satisfaction, any

problems, including dyspareunia. Concerns about HIV infection.

Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, backache. If
present, describe location of affected joints or muscles, any swelling, redness,

pain, tenderness, stiffness, weakness, or 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 symptoms

such as fever, chills, rash, anorexia, weight loss, or weakness.

Psychiatric: Nervousness, tension, mood, including depression, memory
change, suicidal ideation, suicide plans or attempts. Past counseling, psycho-

therapy, or psychiatric admissions.

Neurologic: Changes in mood, attention, or speech; changes in orientation,
memory, insight, or judgment; headache, dizziness, vertigo, fainting, black-

outs; weakness, paralysis, numbness or loss of sensation, tingling or “pins and

needles,” tremors or other involuntary movements, seizures.

Hematologic: Anemia, easy bruising or bleeding, past transfusions, transfusion
reactions.

Endocrine: “Thyroid trouble,” heat or cold intolerance, excessive sweating,
excessive thirst or hunger, polyuria, change in glove or shoe size.

14 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE COMPREHENSIVE PHYSICAL EXAMINATION

Beginning the Examination:
Setting the Stage

Before you begin the adult physical examination, take time to prepare for the
tasks ahead. Think through your approach to the patient, your professional
demeanor, and how to make the patient feel comfortable and relaxed. Review the
measures that promote the patient’s physical comfort and make any adjustments
needed in the environment.

See Chapter 18, Assessing Children:

Infancy Through Adolescence, for

comprehensive pediatric health

histories, pp. 799–925.

Steps in Preparing for the Physical Examination

1. Reflect on your approach to the patient.
2. Adjust the lighting and the environment.
3. Check your equipment.
4. Make the patient comfortable.
5. Observe standard and universal precautions.
6. Choose the sequence, scope, and positioning of examination.

Reflect on Your Approach to the Patient. As you greet the patient, iden-
tify yourself as a student. Appear calm and organized even when you feel inex-
perienced. It is common to forget part of the examination, especially at first.
Simply examine that area out of sequence. It is not unusual to go back to the
patient later and ask to check one or two items that you might have overlooked.

Beginners need to spend more time than seasoned clinicians on selected portions
of the examination, such as the funduscopic examination or cardiac auscultation.
To avoid alarming the patient, warn the patient ahead of time by saying, for
example, “I would like to spend extra time listening to your heart and the heart
sounds, but this doesn’t mean I hear anything wrong.”

Many patients view the physical examination with some anxiety. They feel vulner-
able, physically exposed, apprehensive about possible pain, and uneasy about
what the clinician may find. At the same time, they appreciate your concern about
their health and respond to your attention. With this in mind, the skillful clinician
is thorough without wasting time, systematic but flexible and gentle, yet not afraid
to cause discomfort should this be required. The skillful clinician examines each
region of the body, and at the same time senses the whole patient, notes the wince
or worried glance, and shares information that calms, explains, and reassures.

As a beginner, avoid interpreting your findings. You are not the patient’s primary
caregiver, and your views may be premature or wrong. As you grow in experi-
ence and responsibility, sharing findings will become more appropriate. If the
patient has specific concerns, discuss them with your teachers. At times, you

The Comprehensive Physical
Examination

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THE COMPREHENSIVE PHYSICAL EXAMINATION

may discover abnormalities such as an ominous mass or a deep ulceration.
Always avoid showing distaste, alarm, or other negative reactions.

Adjust the Lighting and the Environment. Several environmental factors
affect the caliber of your examination. For the best results, it is important to “set
the stage” so that both you and the patient are comfortable. Awkward positioning
makes assessing physical findings more difficult for both you and the patient.
Take the time to adjust the bed to a convenient height (but be sure to lower it
when finished), and ask the patient to move toward you, turn over, or shift posi-
tion whenever this makes the examination of selected areas of the body easier.

Good lighting and a quiet environment enhance what you see and hear but may
be hard to arrange. Do the best you can. If a television interferes with auscultat-
ing heart sounds, politely ask the nearby patient to lower the volume, and
remember to thank the patient as you leave.

Tangential lighting is optimal for inspecting structures such as the jugular venous
pulse, the thyroid gland, and the apical impulse of the heart (Fig. 1-3). It casts light
across body surfaces that throw contours, elevations, and depressions, whether
moving or stationary, into sharper relief. When light is perpendicular to the surface
or diffuse, shadows are reduced and subtle undulations across the surface are lost
(Fig. 1-4). Experiment with focused tangential lighting across the tendons on the
back of your hand; try to see the pulsations of the radial artery at your wrist.

Check Your Equipment. Equipment necessary for the physical examination
includes the following:

F I G U R E 1 – 3 . Tangential lighting.

F I G U R E 1 – 4 . Perpendicular

lighting.

Equipment for the Physical Examination

● An ophthalmoscope and an otoscope. If you are examining children, the

otoscope could allow pneumatic otoscopy.
● A flashlight or penlight
● Tongue depressors
● A ruler and a flexible tape measure, preferably marked in centimeters
● Often a thermometer
● A watch with a second hand
● A sphygmomanometer
● A stethoscope with the following characteristics:

● Ear tips that fit snugly and painlessly. To get this fit, choose ear tips of the

proper size, align the ear pieces with the angle of your ear canals, and

adjust the spring of the connecting metal band to a comfortable tightness.
● Thick-walled tubing as short as feasible to maximize the transmission of

sound: ∼30 cm (12 inches), if possible, and no longer than 38 cm (15 inches)
● A bell and a diaphragm with a good changeover mechanism

● A visual acuity card
● A reflex hammer
● Tuning forks, both 128 Hz and 512 Hz

(continued )

16 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

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Make the Patient Comfortable
Patient Privacy and Comfort. Your access to the patient’s body is a unique

and time-honored privilege of your role as a clinician. Showing sensitivity to pri-
vacy and patient modesty must be ingrained in your professional behavior and
conveys respect for the patient’s vulnerability. Close nearby doors, draw the cur-
tains in the hospital or examining room, and wash your hands carefully before the
examination begins.

During the examination, be aware of the patient’s feelings and any discomfort.
Respond to the patient’s facial expressions and even ask, “Are you okay?” or “Is
this painful?” to elicit unexpressed worries or sources of pain. Adjusting the
angle of the bed or examining table, rearranging the pillows, or adding blankets
for warmth demonstrates that you are attentive to the patient’s well-being.

Draping the Patient. You will acquire the art of draping the patient with
the gown or draw sheet as you learn each segment of the examination in the
chapters ahead.

Equipment for the Physical
Examination (continued )

● Cotton swabs, safety pins, or other disposable objects for testing sensation

and two-point discrimination
● Cotton for testing the sense of light touch
● Two test tubes (optional) for testing temperature sensation
● Gloves and lubricant for oral, vaginal, and rectal examinations
● Vaginal specula and equipment for cytologic and bacteriologic studies
● Paper and pen or pencil, or desktop or laptop computer

Tips for Draping the Patient

● Your goal is to visualize one area of the body at a time. This preserves the
patient’s modesty and helps you focus on the area being examined.

● With the patient sitting, for example, untie the gown in back to better listen

to the lungs.
● For the breast examination, uncover the right breast but keep the left chest

draped. Redrape the right chest, then uncover the left chest and proceed to

examine the left breast and heart.
● For the abdominal examination, only the abdomen should be exposed. Adjust

the gown to cover the chest and place the sheet or drape at the inguinal level. To

help the patient prepare for potentially awkward segments of the examination,

briefly describe your plans before starting, for example, “Now I am going to

move your gown so I can check the pulse in your groin area,” or “Because you

mentioned irritation, I am going to inspect your perirectal area.”

Courteous Clear Instructions. Make sure your instructions to the patient
at each step in the examination are courteous and clear. For example, “I would like

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Foundations for Clinical Proficiency 17

THE COMPREHENSIVE PHYSICAL EXAMINATION

to examine your heart now, so please lie down,” or “Now I am going to check your
abdomen.” Let the patient know if you anticipate embarrassment or discomfort.

Keeping the Patient Informed. As you proceed with the examination,
talk with the patient to see if he or she wants to know about your findings. Is the
patient curious about the lung findings or your method for assessing the liver or
spleen?

When you have completed the examination, tell the patient your general impres-
sions and what to expect next. For hospitalized patients, make sure the patient is
comfortable and rearrange the immediate environment to the patient’s satisfaction.
Be sure to lower the bed to avoid risk of falls and raise the bedrails. As you leave,
wash your hands, clean your equipment, and dispose of any waste materials.

Observe Standard and Universal Precautions. The Centers for Disease
Control and Prevention (CDC) have issued several guidelines to protect patients
and examiners from the spread of infectious disease. All clinicians examining
patients are advised to study and observe these precautions at the CDC websites.
Advisories for standard and methicillin-resistant Staphylococcus aureus (MRSA)
precautions and for universal precautions are summarized below.19–23

Standard and MRSA precautions. Standard precautions are based on the principle
that all blood, body fluids, secretions, excretions (except sweat), nonintact skin,
and mucous membranes may contain transmissible infectious agents. Standard
precautions apply to all patients in any setting. They include hand hygiene
(Fig. 1-5); use of personal protective equipment (gloves; gowns; and mouth, nose,
and eye protection) (Fig. 1-6); safe injection practices; safe handling of contami-
nated equipment or surfaces; respiratory hygiene and cough etiquette; patient
isolation criteria; and precautions relating to equipment, toys, solid surfaces, and
laundry handling. Because hand hygiene practices have been shown to reduce the
transmission of multidrug-resistant organisms, especially MRSA and vancomycin-
resistant enterococcus (VRE),19 the CDC hygiene recommendations are repro-
duced below. White coats and stethoscopes also harbor bacteria and should be
cleaned frequently.24,25

F I G U R E 1 – 5 . Handwashing is a

standard precaution.

F I G U R E 1 – 6 . Personal protective

equipment.

CDC Recommendations for Hand Hygiene

1. Key situations where hand hygiene should be performed include:
a. before touching a patient, even if gloves are worn;
b. before exiting the patient’s care area after touching the patient or the

patient’s immediate environment;

c. after contact with blood, body fluids, or excretions, or wound dressings;
d. prior to performing an aseptic task (e.g., placing an intravenous drip, pre-

paring an injection);

e. if hands are moving from a contaminated-body site to a clean-body site
during patient care; and

f. after glove removal.

(continued )

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THE COMPREHENSIVE PHYSICAL EXAMINATION

Universal precautions. Universal precautions are a set of guidelines designed to
prevent parenteral, mucous membrane, and noncontact exposures of health care
workers to bloodborne pathogens, including HIV and HBV. Immunization with
the HBV vaccine for health care workers with exposure to blood is an important
adjunct to universal precautions. The following fluids are considered potentially
infectious: all blood and other body fluids containing visible blood, semen, and
vaginal secretions and cerebrospinal, synovial, pleural, peritoneal, pericardial,
and amniotic fluids. Protective barriers include gloves, gowns, aprons, masks, and
protective eyewear. All health care workers should follow the precautions for safe
injections and prevention of injury from needlesticks, scalpels, and other sharp
instruments and devices. Report to your health service immediately if such
injury occurs.

Choose the Sequence, Scope, and Positioning
of the Examination

The Cardinal Techniques of Examination. As you begin the examina-
tion, study the four cardinal techniques of examination. Plan your sequence and
scope of examination and how you will position the patient.

The physical examination relies on four classic techniques: inspection, palpation,
percussion, and auscultation. You will learn in later chapters about additional
maneuvers that are important in amplifying physical diagnosis, such as having the
patient lean forward to better detect the murmur of aortic regurgitation or ballot-
ing the patella to check for joint effusion.

CDC Recommendations for
Hand Hygiene (continued )

2. Use soap and water when hands are visibly soiled (e.g., blood, body fluids),
or after caring for patients with known or suspected infectious diarrhea

(e.g., Clostridium difficile, norovirus). Otherwise, the preferred method of
hand decontamination is with an alcohol-based hand rub.

Source: CDC. Guide to infection prevention in outpatient settings. Minimum expectations for safe

care. May 2011. Available at http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-guide-

lines.html. Accessed March 1, 2015.

Cardinal Techniques of Examination

Inspection Close observation of the details of the patient’s appearance,
behavior, and movement such as facial expression, mood,

body habitus and conditioning, skin conditions such as

petechiae or ecchymoses, eye movements, pharyngeal

color, symmetry of thorax, height of jugular venous pulsa-

tions, abdominal contour, lower extremity edema, and gait.

(continued )

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THE COMPREHENSIVE PHYSICAL EXAMINATION

Sequence of Examination. The key to a thorough and accurate physi-
cal examination is developing a systematic sequence of examination. Organize
your comprehensive or focused examination around three general goals:

■ Maximize the patient’s comfort.

â–  Avoid unnecessary changes in position.

â–  Enhance clinical efficiency.

In general, move from “head to toe.” Avoid examining the patient’s feet, for exam-
ple, before checking the face or mouth. You will quickly see that some segments of
the examination are best assessed when the patient is sitting, such as examination
of the head and neck and the thorax and lungs, whereas others are best obtained
with the patient supine, such as the cardiovascular and abdominal examinations.

As you review the Techniques of Examination on the following pages, note
that clinicians vary in where they place different segments of the examination,
especially examinations of the musculoskeletal system and the nervous sys-
tem. Some of these options are indicated in red in the right-hand column.
Suggestions for patient positioning during the different segments of the exam-
ination are also indicated in the right-hand column in red.

With practice, you will develop your own sequence of examination, keeping the
need for thoroughness and patient comfort in mind. At first, you may need notes
to remind you what to look for, but over time, this sequence will become habit-
ual and remind you to return to segments of the examination you may have
skipped, helping you to be complete.

Cardinal Techniques of Examination (continued )

Palpation Tactile pressure from the palmar fingers or fingerpads to
assess areas of skin elevation, depression, warmth, or ten-

derness, lymph nodes, pulses, contours and sizes of organs

and masses, and crepitus in the joints.

Percussion Use of the striking or plexor finger, usually the third, to deliver
a rapid tap or blow against the distal pleximeter finger, usu-
ally the distal third finger of the left hand laid against the

surface of the chest or abdomen, to evoke a sound wave

such as resonance or dullness from the underlying tissue or

organs. This sound wave also generates a tactile vibration

against the pleximeter finger.

Auscultation Use of the diaphragm and bell of the stethoscope to detect the
characteristics of heart, lung, and bowel sounds, including

location, timing, duration, pitch, and intensity. For the

heart, this involves sounds from closure of the four valves,

extra sounds from blood flow into the atria and ventricles,

and murmurs. Auscultation also permits detection of bruits

or turbulence over arterial vessels.

20 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE COMPREHENSIVE PHYSICAL EXAMINATION

Examining from the Patient’s Right Side. This book recommends
examining the patient from the patient’s right side, moving to the opposite side or
foot of the bed or examining table as necessary. This is the standard position for the
physical examination and has several advantages compared with the left side: Esti-
mates of jugular venous pressure are more reliable, 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.

Left-handed students are encouraged to adopt right-sided positioning, even it
may seem awkward. The left hand can still be used for percussing or for holding
instruments such as the otoscope or reflex hammer.

Review the proposed physical examination sequence in Figure 1-6, which meets
the three goals of patient comfort, minimal changes in positioning, and efficiency.

The Physical Examination: Suggested Sequence and Positioning

Head and neck, including thyroid and lymph nodes

Musculoskeletal as indicated: upper extremities

Cardiovascular, including jugular venous pressure (JVP),
carotid upstrokes and bruits, point of maximal
impulse (PMI), S1, S2; murmurs, extra sounds

Cardiovascular, for S3 and murmur of
mitral stenosis

Cardiovascular, for murmur of aortic insufficiency

Peripheral vascular

Optional: thorax and lungs—anterior

Abdomen

Breasts and axillae

Optional: nervous system (mental status,
cranial nerves, upper extremity motor
strength, bulk, tone, cerebellar function)

General survey

Vital signs

Thorax and lungs

Breasts

Skin: upper torso, anterior and posterior

Optional: skin—lower torso and extremities

Each symbol pertains until a new one

appears. Two symbols separated by

a slash indicate either or both positions.

Sitting

Lying supine, with head
of bed raised 30 degrees

Same, turned partly to
left side

Sitting, leaning forward

Lying supine

Standing

Lying supine, with hips
flexed, abducted, and
externally rotated, and
knees flexed (lithotomy
position)

Lying on the left side
(left lateral decubitus)

Key to the Symbols for the Patient’s Position

Nervous system: lower extremity
motor strength, bulk, tone,
sensation; reflexes; Babinski reflex

Musculoskeletal, as indicated

Optional: skin, anterior and posterior

Optional: nervous system, including gait

Optional: musculoskeletal, comprehensive

Women: pelvic and rectal examination

Men: prostate and rectal examination

Examining the Patient at Bedrest. Often you will need to examine a
patient at bedrest, especially in the hospital, where patients frequently cannot sit up
in bed or stand. This often dictates changes in your sequence of examination. You
can examine the head, neck, and anterior chest with the patient lying supine.

C H A P T E R 1 |

Foundations for Clinical Proficiency 21

THE COMPREHENSIVE PHYSICAL EXAMINATION

Then, roll the patient onto each side to listen to the lungs, examine the back, and
inspect the skin. Roll the patient back and finish the rest of the examination with
the patient again supine.

The Physical Examination—“Head to Toe”

General Survey. Observe the patient’s general state of health, height, build,
and sexual development. Obtain the patient’s height and weight. Note posture,
motor activity, and gait; dress, grooming, and personal hygiene; and any odors
of the body or breath. Watch the patient’s facial expressions and note manner,
affect, and reactions to people and the environment. Listen to the patient’s
speech, and note the state of awareness or level of consciousness.

Vital Signs. Measure the blood pressure. Count the pulse and respiratory
rate. If indicated, measure the body temperature.

Skin. Observe the skin of the face and its characteristics. Assess skin moisture
or dryness and temperature. Identify any lesions, noting their location, distribu-
tion, arrangement, type, and color. Inspect and palpate the hair and nails. Study
both surfaces of the patient’s hands. Continue your assessment of the skin as you
examine the other body regions.

Head, Eyes, Ears, Nose, Throat (HEENT). Head: Examine the hair, scalp,
skull, and face. Eyes: Check visual acuity and screen the visual fields. Note the
position and alignment of the eyes. Observe the eyelids and inspect the sclera
and conjunctiva of each eye. With oblique lighting, inspect each cornea, iris, and
lens. Compare the pupils, and test their reactions to light. Assess the extraocular
movements. With an ophthalmoscope, inspect the ocular fundi. Ears: Inspect
the auricles, canals, and drums. Check auditory acuity. If acuity is diminished,
check lateralization (Weber test) and compare air and bone conduction (Rinne
test). Nose and sinuses: Examine the external nose; using a light and a nasal
speculum, inspect the nasal mucosa, septum, and turbinates. Palpate for tender-
ness of the frontal and maxillary sinuses. Throat (or mouth and pharynx):
Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and pharynx.
(You may wish to assess the cranial nerves during this portion of the examination.)

Neck. Inspect and palpate the cervical lymph nodes. Note any masses or
unusual pulsations in the neck. Feel for any deviation of the trachea. Observe the
sound and effort of the patient’s breathing. Inspect and palpate the thyroid gland.

Back. Inspect and palpate the spine and muscles of the back. Observe shoul-
der height for symmetry.

Posterior Thorax and Lungs. Inspect and palpate the spine and muscles of
the upper back. Inspect, palpate, and percuss the chest. Identify the level of dia-
phragmatic dullness on each side. Listen to the breath sounds; identify any
adventitious (or added) sounds, and, if indicated, listen to the transmitted voice
sounds (see pp. 326–327).

Close observation begins at the out-

set of the patient encounter and con-

tinues throughout the history and

physical examination.

The patient is sitting on the edge of

the bed or examining table. Stand in

front of the patient, moving to either

side as needed.

The room should be darkened for

the ophthalmoscopic examination.

This promotes pupillary dilation and

visibility of the fundi.

Move behind the sitting patient to

feel the thyroid gland and to examine

the back, posterior thorax, and lungs.

22 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE COMPREHENSIVE PHYSICAL EXAMINATION

Breasts, Axillae, and Epitrochlear Nodes. In a woman, inspect the breasts
with her arms relaxed, then elevated, and then with her hands pressed on her
hips. In either sex, inspect the axillae and feel for the axillary nodes. Feel for the
epitrochlear nodes.

A Note on the Musculoskeletal System. By this time, you have made
preliminary observations of the musculoskeletal system. You have inspected
the hands, surveyed the upper back, and, in women, made a fair estimate of
the shoulders’ range of motion. If indicated, with the patient still sitting, exam-
ine the hands, arms, shoulders, neck, and temporomandibular joints. Inspect
and palpate the joints and check their range of motion. (You may choose to
examine upper extremity muscle bulk, tone, strength, and reflexes at this time, or
wait until later.)

Palpate the breasts, while at the same time continuing your inspection.

Anterior Thorax and Lungs. Inspect, palpate, and percuss the chest. Listen
to the breath sounds, any adventitious sounds, and, if indicated, transmitted
voice sounds.

Cardiovascular System. Observe the jugular venous pulsations and mea-
sure the jugular venous pressure in relation to the sternal angle. Inspect and
palpate the carotid pulsations. Listen for carotid bruits.

Elevate the head of the bed to ∼30º for the cardiovascular examination, adjust-
ing as necessary to see the jugular venous pulsations.

Inspect and palpate the precordium. Note the location, diameter, amplitude, and
duration of the apical impulse. Listen at each auscultatory area with the dia-
phragm of the stethoscope. Listen at the apex and the lower sternal border with
the bell. Listen for the first and second heart sounds and for physiologic splitting
of the second heart sound. Listen for any abnormal heart sounds or murmurs.

Abdomen. Inspect, auscultate, and percuss the abdomen. Palpate lightly, then
deeply. Assess the liver and spleen by percussion and then palpation. Try to pal-
pate the kidneys. Palpate the aorta and its pulsations. If you suspect kidney infec-
tion, percuss posteriorly over the costovertebral angles.

Lower Extremities. Examine the legs, assessing three systems while the
patient is still supine. Each of these three systems can be further assessed when
the patient stands.

With the patient supine:

â–  Peripheral vascular system. Palpate the femoral pulses and, if indicated, the
popliteal pulses. Palpate the inguinal lymph nodes. Inspect for lower extrem-
ity edema, discoloration, or ulcers. Palpate for pitting edema.

The patient is still sitting. Move to the

front again.

The patient position is supine. Ask

the patient to lie down. You should

stand at the right side of the patient’s
bed.

Ask the patient to roll partly onto the

left side while you listen at the apex

for an S3 or mitral stenosis. The patient
should sit, lean forward, and exhale

while you listen for the murmur of

aortic regurgitation.

Lower the head of the bed to the flat

position. The patient should be supine.

The patient is supine.

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Foundations for Clinical Proficiency 23

THE COMPREHENSIVE PHYSICAL EXAMINATION

â–  Musculoskeletal system. Note any deformities or enlarged joints. If indicated,
palpate the joints, check their range of motion, and perform any necessary
maneuvers.

â–  Nervous system. Assess lower extremity muscle bulk, tone, and strength; also
assess sensation and reflexes. Observe any abnormal movements.

With the patient standing:

â–  Peripheral vascular system. Inspect for varicose veins.

â–  Musculoskeletal system. Examine the alignment of the spine and its range of
motion, the alignment of the legs, and the feet.

â–  Genitalia and hernias in men. Examine the penis and scrotal contents and
check for hernias.

■ Nervous system. Observe the patient’s gait and ability to walk heel-to-toe,
walk on the toes, walk on the heels, hop in place, and do shallow knee
bends. Do a Romberg test and check for pronator drift.

Nervous System. The complete examination of the nervous system can
also be done at the end of the examination. It consists of the five segments:
mental status, cranial nerves (including funduscopic examination), motor sys-
tem, sensory system, and reflexes.

Mental Status. If indicated and not done during the interview, assess the
patient’s orientation, mood, thought process, thought content, abnormal percep-
tions, insight and judgment, memory and attention, information and vocabulary,
calculating abilities, abstract thinking, and constructional ability.

Cranial Nerves. If not already examined, check sense of smell, strength of
the temporal and masseter muscles, corneal reflexes, facial movements, gag
reflex, and strength of the trapezia and sternocleidomastoid muscles.

Motor System. Assess 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.

Sensory System. Assess pain, temperature, light touch, vibration, and
discrimination. Compare right with left sides and distal with proximal areas on
the limbs.

Reflexes. Including biceps, triceps, brachioradialis, patellar, Achilles deep
tendon reflexes; also plantar reflexes or Babinski response (see pp. 758–764).

Additional Examinations. The rectal and genital examinations are often
performed at the end of the physical examination. Patient positioning is as
indicated.

The patient is standing. You can sit on

a chair or stool.

The patient is sitting or supine.

24 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

CLINICAL REASONING, ASSESSMENT, AND PLAN

Genital and Rectal Examination in Men. 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.

Genital and Rectal Examinations in Women. Examine the external
genitalia, vagina, and cervix, with a chaperone when needed. Obtain a Pap
smear. Palpate the uterus and adnexa bimanually. Perform the rectal examination
if indicated.

F I G U R E 1 – 7 . Discuss the

assessment.

F I G U R E 1 – 8 . Share the plan.

The patient is lying on his left side for

the rectal examination (or standing

and bending forward).

The patient is supine in the lithotomy

position. You should be seated during

examination with the speculum, then

standing during bimanual examination

of the uterus, adnexa (and rectum as

indicated).

Clinical Reasoning,
Assessment, and Plan

After completing the history and physical examination, you reach the critical
step of formulating your Assessment and Plan (Figs. 1-7 and 1-8). Using sound
clinical reasoning, you must analyze your findings and identify the patient’s
problems. You must share your impressions with the patient, eliciting any con-
cerns and making sure that he or she understands and agrees to the steps ahead.
Finally, you must document your findings in the patient’s record in a succinct
legible format that communicates the patient’s story and physical findings, 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, specificity, 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 subjective data of the health history and the objec-
tive data from the physical examination and testing are primarily descriptive and
factual. As you move to Assessment, you go beyond description and observa-
tion to analysis and interpretation. You select and cluster relevant pieces of
information, analyze their significance, and try to explain them logically using
principles of biopsychosocial and bioclinical science. Your clinical reasoning
process is pivotal to how you interpret the patient’s history and physical examina-
tion, single out problems identified in the Assessment, and move from each prob-
lem to its action plan (Fig. 1-9).

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. However, a successful Plan does more than just
describe the approach to a problem. It includes the patient’s responses to the
problems identified and to the diagnostic and therapeutic interventions that
you recommend. It requires good interpersonal skills and sensitivity to the
patient’s goals, economic means, competing responsibilities, and family struc-
ture and dynamics.

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Foundations for Clinical Proficiency 25

CLINICAL REASONING, ASSESSMENT, AND PLAN

Clinical Reasoning and Assessment

Because assessment takes place in the clinician’s mind, the process of clinical
reasoning may seem opaque and even mysterious to beginning students.
Experienced clinicians often think quickly, with little overt or conscious effort.
They differ widely in personal style, communication skills, clinical training,
experience, and expertise. Some clinicians may find it difficult to explain the
logic behind their clinical thinking. As an active learner, you will be expected to
ask teachers and clinicians to elaborate on the fine points of their clinical reason-
ing and decision making.26,27

Cognitive psychologists have shown that clinicians use three types of reasoning
for clinical problem solving: pattern recognition, development of schemas, and
application of relevant basic and clinical science.29–34 As you gain experience,
your clinical reasoning will begin at the outset of the patient encounter, not at
the end. Study the steps described here, then apply them to the Case of Mrs. N.
that follows. Think about these steps as you see your first patients. As with all
patients, focus on determining “What explains this patient’s concerns?” and
“What are the findings, problems, and diagnoses?”17,35

F I G U R E 1 – 9 . Apply clinical

reasoning.

For clinical examples of excellent

and faulty reasoning and strategies

to avoid cognitive errors, turn to

Kassirer et al., Learning Clinical
Reasoning.28

Steps for Identifying Problems and
Making Diagnoses

1. Identify abnormal findings.
2. Localize findings anatomically.
3. Cluster the clinical findings.
4. Search for the probable cause of the findings.
5. Cluster the clinical data.
6. Generate hypotheses about the causes of the patient’s problems.
7. Test the hypotheses and establish a working diagnosis.

Identify Abnormal Findings. Make a list of the patient’s symptoms, the signs
you observed during the physical examination, and any laboratory reports avail-
able to you.

Localize These Findings Anatomically. Often, this step is straightfor-
ward. The symptom of scratchy throat and the sign of an erythematous inflamed
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 difficulty. Chest pain,
for example, can originate in the coronary arteries, the stomach and esopha-
gus, or the muscles and bones of the thorax. If the pain is exertional and
relieved by rest, either the heart or the musculoskeletal components of the
chest wall may be involved. If the patient notes pain only when carrying gro-
ceries with the left arm, the musculoskeletal system becomes the likely culprit.

When localizing findings, be as specific 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

26 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

CLINICAL REASONING, ASSESSMENT, AND PLAN

musculoskeletal system. On the other hand, you may be able to define 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.

Cluster the Clinical Findings. It is often challenging to decide whether
clinical data fit into one problem or several problems. If there is a relatively long
list of symptoms and signs, and an equally long list of potential explanations, one
approach is to tease out separate clusters of observations and analyze one cluster at a
time. 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.

â–  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 office 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 pain-
less penile ulcer suggests two problems: gonorrhea and primary syphilis. In
contrast, a penile ulcer followed in 6 weeks by a maculopapular skin rash
and generalized lymphadenopathy suggest two stages of the same problem:
primary and secondary syphilis.

â–  Involvement of different body systems: Involvement of the different body systems
may help group clinical data. 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. Again, knowledge of dis-
ease patterns is necessary. For example, you might decide to group a patient’s
high blood pressure and sustained apical impulse together with flame-
shaped retinal hemorrhages, place them in the cardiovascular system, and
label the constellation “hypertensive cardiovascular disease with hyperten-
sive retinopathy.” You would develop another explanation for the patient’s
mild fever, left lower quadrant tenderness, and diarrhea.

â–  Multisystem conditions: With experience, you will become increasingly adept
at recognizing multisystem conditions and building plausible explanations that
link manifestations that are seemingly unrelated. To explain cough, hemop-
tysis, 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. With experience and continued reading, you will recog-
nize that his other symptoms and signs fall under the same diagnosis. Dys-
phagia would reflect extension of the cancer to the esophagus, pupillary
asymmetry would suggest pressure on the cervical sympathetic chain, and
jaundice could result from metastases to the liver. In another example of
multisystem disease, a young man who presents with odynophagia, fever,
weight loss, purplish skin lesions, leukoplakia, generalized lymphadenopa-
thy, and chronic diarrhea is likely to have acquired immune deficiency syn-
drome (AIDS). Related risk factors should be explored promptly.

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Foundations for Clinical Proficiency 27

CLINICAL REASONING, ASSESSMENT, AND PLAN

â–  Key questions: You can also ask a series of key questions that may steer your
thinking in one direction and allow you to temporarily ignore the others. For
example, you may ask what produces and relieves the patient’s chest pain. If
the answer is exercise and rest, you can focus on the cardiovascular and
musculoskeletal systems and set the gastrointestinal (GI) system aside. If the
pain is more epigastric, burning, and occurs only after meals, you can logi-
cally focus on the GI tract. A series of discriminating questions helps you
analyze the clinical data and reach logical explanations.

Search for the Probable Cause of the Findings. Patient complaints often
stem from a pathologic process involving diseases of a body system or structure.
These processes are commonly classified as congenital, inflammatory or infec-
tious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular,
traumatic, and toxic. Possible pathologic causes of headache, for example,
include sinus infection, concussion from trauma, subarachnoid hemorrhage,
or even compression from a brain tumor. Fever and stiff neck, or nuchal rigidity,
are two of the classic signs of headache from meningitis. Even without
other signs, such as rash or papilledema, they strongly suggest an infectious
process.

Other problems are pathophysiologic, reflecting derangements of biologic func-
tions, such as heart failure or migraine headache. Still other problems are psycho-
pathologic, such as disorders of mood like depression or headache as an expression
of a somatic symptom disorder.

Generate Hypotheses About the Causes of the Patient’s Problem.
Draw on the full range of your knowledge and experience, and read widely. It
is at this point that reading about diseases and abnormalities is most useful. By
consulting the clinical literature, you embark on the lifelong goal of evidence-
based decision making and clinical practice.14,36–39 At first, your hypotheses may
not be highly specific, but proceed as far as your knowledge and available data
allow, observing the steps below.

Steps for Generating Clinical Hypotheses

1. Select the most specific and critical findings to support your hypothesis. If the
patient reports “the worst headache of her life,” nausea, and vomiting, for

example, and you find altered mental status, papilledema, and meningismus,

build your hypothesis around elevated intracranial pressure rather than GI

disorders.

2. Match your findings against all the conditions that can produce them. Using
your knowledge of the structures and processes involved, you can match

your patient’s papilledema with a list of conditions affecting intracranial

pressure. Or you can compare the symptoms and signs associated with the

patient’s headache with the various infectious, vascular, metabolic, or neo-

plastic conditions that might produce this clinical picture.

3. Eliminate the diagnostic possibilities that fail to explain the findings. You
might consider cluster headache as a cause of Mrs. N.’s headaches (see

(continued )

28 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

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Test Your Hypotheses. Now that you have made a hypothesis about the
patient’s problem, you are ready to test your hypothesis. You are likely to need
further history, additional maneuvers on physical examination, or laboratory
studies or x-rays to confirm or rule out your tentative diagnosis or to clarify
which of two or three possible diagnoses are most likely. When the diagnosis
seems clear-cut—a simple upper respiratory infection or a case of hives, for
example—these steps may not be necessary.

Establish a Working Diagnosis. Establish a working definition of the prob-
lem at the highest level of explicitness and certainty that the data allow. You may
be limited to a symptom, such as “tension headache, cause unknown.” At other
times, you can define a problem more specifically based on its anatomy, disease
process, or cause. Examples include “bacterial meningitis, pneumococcal,” “sub-
arachnoid hemorrhage, left temporoparietal lobe,” or “hypertensive cardiovascu-
lar disease with left ventricular dilatation and heart failure.”

Although most diagnoses are based on the identification of abnormal structures,
disease processes, and clinical syndromes, patients frequently have clinically unex-
plained symptoms. You may not be able to move beyond simple descriptive cate-
gories such as “fatigue” or “anorexia.” Other problems relate to stressful events in

See Chapter 2, Evaluating Clinical

Evidence, pp. 45–64.

Steps for Generating Clinical Hypotheses (continued )

The Case of Mrs. N., pp. 30–36), but eliminate this hypothesis because it
fails to explain the patient’s throbbing bifrontal localization with associ-

ated nausea and vomiting. Also, the pain pattern is atypical for cluster

headache—it is not unilateral, boring, or occurring repetitively at the

same time over a period of days, nor is it associated with lacrimation or

rhinorrhea.

4. Weigh the competing possibilities and select the most likely diagnosis. You are
looking for a close match between the patient’s clinical presentation and

a typical case of a given condition. Other clues help in this selection. The

statistical probability of a given disease in a patient of this age, sex, ethnic
group, habits, lifestyle, and locality should greatly influence your selec-

tion. You should consider the possibilities of osteoarthritis and metastatic

prostate cancer in a 70-year-old man with back pain, for example, but not

in a 25-year-old woman with the same complaint. The timing of the patient’s
illness also makes a difference. Headache in the setting of fever, rash, and
stiff neck that develops suddenly over 24 hours suggests quite a different

problem than recurrent headache over a period of years associated with

stress, visual scotoma, and nausea and vomiting relieved by rest.

5. Give special attention to potentially life-threatening conditions. Your goal is to
minimize the risk of missing unusual or infrequent conditions such as menin-

gococcal meningitis, bacterial endocarditis, pulmonary embolus, or subdural

hematoma that are particularly ominous. One rule of thumb is always to
include “the worst case scenario” in your differential diagnosis and make
sure you have ruled out this possibility based on your findings and patient
assessment.

C H A P T E R 1 |

Foundations for Clinical Proficiency 29

THE QUALITY CLINICAL RECORD: THE CASE OF MRS. N.

the patient’s life such as losing a job or a family member that increase the risk for
subsequent illness. Identifying these events and helping the patient develop coping
strategies are just as important as managing a headache or a duodenal ulcer.

Another increasingly prominent item on problem lists is Health Maintenance.
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.

Using Shared Decision-Making to
Develop a Plan

Identify and record a Plan for each patient problem. Your Plan flows logically
from the problems or diagnoses you have identified. Specify the next steps for
each problem. These steps range from tests and procedures to subspecialty con-
sultations to new or changed medications to arranging a family meeting. You will
find that you follow many of the same diagnoses over time; however, your Plan
is often more fluid, encompassing changes and modifications that emerge from
each patient visit. The Plan should make reference to diagnosis, treatments, and
patient education. It is important to discuss your assessment with the patient
before finalizing the Plan and proceeding with further testing or evaluation,
ensuring the patient’s active participation in the plan of care (Fig. 1-10). It is
critical to both obtain patient agreement and encourage patient participation
in decision-making whenever possible. These practices promote optimal ther-
apy, adherence to treatment, and patient satisfaction, especially since there is
often no single “right” plan, but a range of variations and options. You may need
to explain your recommendations several times to make sure the patient agrees
to and understands what lies ahead.

F I G U R E 1 – 1 0 . Make sure the

patient agrees with the plan.

See Chapter 5, Behavior and Mental

Status, section on “Medically Unex-

plained Symptoms,” pp. 149–150.

The Quality Clinical Record:
The Case of Mrs. N.

The clinical record serves a dual purpose—it reflects 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 writ-
ten format (Fig. 1-11). In a well-constructed record, each problem in the
Assessment is listed in order of priority with an explanation of supporting find-
ings and a differential diagnosis, followed by a Plan for addressing that prob-
lem. The patient record facilitates clinical reasoning, promotes communication
and coordination among the professionals who care for your patient, and doc-
uments the patient’s problems and management for medicolegal purposes.

Compose the clinical record as soon after seeing the patient as possible, before
your findings fade from memory. At first you may take notes, but work toward
recording each segment of the health history during the interview, leaving spaces

F I G U R E 1 – 1 1 . Compose a well-

constructed record.

30 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE QUALITY CLINICAL RECORD: THE CASE OF MRS. N.

for filling in details later. Jot down blood pressure, heart rate, and key abnormal
findings to prompt your recall when you complete the record later.

Almost all clinical information is subject to error. Patients forget to mention
symptoms, confuse the events of their illness, avoid recounting embarrassing
facts, and may slant their stories to what they believe the clinician wants to hear.
Clinicians misinterpret patient statements, overlook information, fail to ask “the
one key question,” jump prematurely to conclusions and diagnoses, or forget an
important part of the examination, such as the funduscopic examination in a
woman with headache, leading to diagnostic errors.40–48 You can avoid some of
these errors by acquiring the habits summarized below.

Tips for Ensuring Quality Patient Data

● Ask open-ended questions and listen carefully to the patient’s story.
● Craft a thorough and systematic sequence to history taking and physical

examination.
● Keep an open mind toward both the patient and the clinical data.
● Always include “the worst-case scenario” in your list of possible explanations

of the patient’s problem, and make sure it can be safely eliminated.
● Analyze any mistakes in data collection or interpretation.
● Confer with colleagues and review the pertinent clinical literature to clarify

uncertainties.
● Apply the principles of evaluating clinical evidence to patient information and

testing.

Study the case of Mrs. N. and scrutinize the history, physical examination, assess-
ment, and plan. Note the standard format of the clinical record. Apply your own
clinical reasoning to the findings presented and begin to analyze the patient’s
concerns. See if you agree with the Assessment and Plan and the priority of the
problems listed.

The Case of Mrs. N.

8/25/16 11:00 am

Mrs. N. is a pleasant, 54-year-old widowed saleswoman residing in Espanola,

New Mexico.

Referral. None
Source and Reliability. Self-referred; seems reliable.

Chief Complaint
“My head aches.”

Present Illness
Mrs. N. reports increasing problems with frontal headaches over the past 3

months. These are usually bifrontal, throbbing, and mild to moderately severe.

She has missed work on several occasions because of associated nausea and

vomiting. Headaches now average once a week, usually related to stress, and
(continued )

See Table 1-1, p. 41, for a Sample

Progress Note for the follow-up visit

of Mrs. N.

C H A P T E R 1 |

Foundations for Clinical Proficiency 31

THE QUALITY CLINICAL RECORD: THE CASE OF MRS. N.

The Case of Mrs. N. (continued )

last 4 to 6 hours. They are relieved by sleep and putting a damp towel over her

forehead. There is little relief from aspirin. There are no associated visual

changes, motor-sensory deficits, or paresthesias.

She had headaches with nausea and vomiting beginning at age 15 years.

These recurred throughout her mid-20s, then decreased to one every 2 or

3 months, and almost disappeared.

The patient reports increased pressure at work from a demanding supervisor;

she is also worried about her daughter (see Personal and Social History). She thinks
her headaches may be like those in the past, but wants to be sure because her

mother had a headache just before she died of a stroke. She is concerned because

her headaches interfere with her work and make her irritable with her family. She

eats three meals a day and drinks three cups of coffee a day and tea at night.

Medications. Acetominophen, 1 to 2 tablets every 4 to 6 hours as needed.
“Water pill” in the past for ankle swelling, none recently.

Allergies. Ampicillin causes rash.
Tobacco. About 1 pack of cigarettes per day since age 18 (36 pack-years).
Alcohol/drugs. Wine on rare occasions. No illicit drugs.

Past History
Childhood Illnesses: Measles, chickenpox. No scarlet fever or rheumatic fever.
Adult Illnesses: Medical: Pyelonephritis, 1998, with fever and right flank
pain; treated with ampicillin; developed generalized rash with itching sev-

eral days later. Reports x-rays were normal; no recurrence of infection.

Surgical: Tonsillectomy, age 6; appendectomy, age 13. Sutures for lacera-
tion, 2001, after stepping on glass. Ob/Gyn: 3–3–0–3, with normal vaginal
deliveries. Three living children. Menarche age 12. Last menses 6 months

ago. Little interest in sex, and not sexually active. No concerns about HIV

infection. Psychiatric: None.
Health Maintenance: Immunizations: Oral polio vaccine, year uncertain; teta-
nus shots × 2, 1982, followed with booster 1 year later; flu vaccine, 2000, no reac-
tion. Screening tests: Last Pap smear, 2014, normal. No mammograms to date.

Train accident Stroke, varicose veins, headaches
43 67

High
blood

pressure
Heart
attack

Infancy
67 58 54

33 31 27
Headaches

Migraine
headaches

Indicates patient

Deceased male

Deceased female

Living male

Living female

(continued )

Gravida (G)-Parity (# of deliveries)

(P)-Miscarriages (M)-Living (L), or

G-P-M-L 3–3–0–3

32 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE QUALITY CLINICAL RECORD: THE CASE OF MRS. N.

The Case of Mrs. N. (continued )

Family History
The family history is depicted above.

Father died at age 43 years in a train accident. Mother died at age 67 years from

stroke; had varicose veins, headaches.

One brother, age 61 years, with hypertension, otherwise well; one brother, age 58

years, well except for mild arthritis; one sister, died in infancy of unknown cause.

Husband died at age 54 of heart attack

Daughter, age 33 years, with migraine headaches, otherwise well; son, age

31 years, with headaches; son, age 27 years, well.

No family history of diabetes, tuberculosis, heart or kidney disease, cancer,

anemia, epilepsy, or mental illness.

Personal and Social History
Born and raised in Las Cruces, finished high school, married at age 19 years.

Worked as sales clerk for 2 years, then moved with husband to Espanola, had three

children. Returned to work 15 years ago to improve family finances. Children all

married. Four years ago Mr. N. died suddenly of a heart attack, leaving little sav-

ings. Mrs. N. has moved to a small apartment to be near daughter, Isabel. Isabel’s

husband, John, has an alcohol problem. Mrs. N.’s apartment is now a haven for Isa-

bel and her two children, Kevin, age 6 years, and Lucia, age 3 years. Mrs. N. feels

responsible for helping them; she feels tense and nervous, but denies depression.

She has friends, but rarely discusses family problems: “I’d rather keep them to

myself. I don’t like gossip.” No church or other organizational support. She is

typically up at 7:00 am, works 9:00 am to 5:30 pm, and eats dinner alone.

Exercise and diet. Gets little exercise. Diet high in carbohydrates.
Safety measures. Uses seat belt regularly. Uses sunblock. Medications kept in

an unlocked medicine cabinet. Cleaning solutions in unlocked cabinet

below sink. Mr. N.’s shotgun and box of shells in unlocked closet upstairs.

Review of Systems
General: Has gained 10 lbs in the past 4 years.
Skin: No rashes or other changes.
Head, Eyes, Ears, Nose, Throat (HEENT): See Present Illness. Head: No history of
head injury. Eyes: Reading glasses for 5 years, last checked 1 year ago. No symptoms.
Ears: Hearing good. No tinnitus, vertigo, infections. Nose, sinuses: Occasional mild
cold. No hay fever, sinus trouble. Throat (or mouth and pharynx): Some bleeding of
gums recently. Last dental visit 2 years ago. Occasional canker sore.

Neck: No lumps, goiter, pain. No swollen glands.
Breasts: No lumps, pain, discharge. Does breast self-examination sporadically.
Respiratory: No cough, wheezing, shortness of breath. Last chest x-ray, 1986,
St. Mary’s Hospital; unremarkable.

Cardiovascular: No known heart disease or high blood pressure; last blood
pressure taken in 2007. No dyspnea, orthopnea, chest pain, palpitations. Has

never had an electrocardiogram (ECG).

Gastrointestinal: Appetite good; no nausea, vomiting, indigestion. Bowel move-
ment about once daily, though sometimes has hard stools for 2 to 3 days when espe-

cially tense; no diarrhea or bleeding. No pain, jaundice, gallbladder or liver problems.

(continued )

The Family History can be recorded as

a diagram or a narrative. The diagram

is more helpful for tracing genetic dis-

orders. The negatives from the family

history should follow either format.

C H A P T E R 1 |

Foundations for Clinical Proficiency 33

THE QUALITY CLINICAL RECORD: THE CASE OF MRS. N.

The Case of Mrs. N. (continued )

Urinary: No frequency, dysuria, hematuria, or recent flank pain; nocturia × 1,
large volume. *Occasionally loses urine when coughing.

Genital: No vaginal or pelvic infections. No dyspareunia.
Peripheral vascular: Varicose veins appeared in both legs during first preg-
nancy. For 10 years, has had swollen ankles after prolonged standing; wears light

elastic support hose; tried “water pill” 5 months ago, but it didn’t help much; no

history of phlebitis or leg pain.

Musculoskeletal: Mild low backaches, often at the end of the workday; no radia-
tion into the legs; used to do back exercises, but not now. No other joint pain.

Psychiatric: No history of depression or treatment for psychiatric disorders.
(See also Present Illness and Personal and Social History.)
Neurologic: No fainting, seizures, motor or sensory loss. Memory good.
Hematologic: Except for bleeding gums, no easy bleeding. No anemia.
Endocrine: No known thyroid disorders or heat or cold intolerance. No symp-
toms or history of diabetes.

PHYSICAL EXAMINATION
Mrs. N. is a short, overweight, middle-aged woman, who is animated and

responds quickly to questions. She is somewhat tense, with moist, cold hands.

Her hair is well groomed. Her color is good, and she lies flat without discomfort.

Vital signs: Ht (without shoes) 157 cm (5′2″). Wt (dressed) 65 kg (143 lb). BMI
26. BP 164/98 right arm, supine; 160/96 left arm, supine; 152/88 right arm, supine

with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18. Temper-

ature (oral) 98.6 °F.
Skin: Palms cold and moist, but color good. Scattered cherry angiomas over
upper trunk. Nails without clubbing, cyanosis.

Head, Eyes, Ears, Nose, Throat (HEENT): Head: Hair of average texture. Scalp
without lesions, normocephalic/atraumatic (NC/AT). Eyes: Vision 20/30 in each
eye. Visual fields full by confrontation. Conjunctiva pink; sclera white. Pupils 4

mm constricting to 2 mm, round, regular, equally reactive to light. Extraocular

movements intact. Disc margins sharp, without hemorrhages, exudates. No

arteriolar narrowing or A-V nicking. Ears: Wax partially obscures right tympanic
membrane (TM); left canal clear, TM with good cone of light. Acuity good to

whispered voice. Weber midline. AC > BC. Nose: Mucosa pink, septum midline.
No sinus tenderness. Mouth: Oral mucosa pink. Several interdental papillae red,
slightly swollen. Dentition good. Tongue midline, with 3 × 4 mm shallow white
ulcer on red base on undersurface near tip; tender but not indurated. Tonsils

absent. Pharynx without exudates.

Neck: Neck supple. Trachea midline. Thyroid isthmus barely palpable, lobes
not felt.

Lymph nodes: Small (<1 cm), soft, nontender, and mobile tonsillar and poste-
rior cervical nodes bilaterally. No axillary or epitrochlear nodes. Several small

inguinal nodes bilaterally, soft and nontender.

Thorax and lungs: Thorax symmetric with good excursion. Lungs resonant.
Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm

bilaterally.

(continued )

34 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE QUALITY CLINICAL RECORD: THE CASE OF MRS. N.

The Case of Mrs. N. (continued )

Cardiovascular: Jugular venous pressure 1 cm above the sternal angle, with
head of examining table raised to 30º. Carotid upstrokes brisk, without bruits.

Apical impulse discrete and tapping, barely palpable in the 5th left interspace, 8

cm lateral to the midsternal line. Good S1, S2; no S3 or S4. A II/VI medium-pitched

midsystolic murmur at the 2nd right interspace; does not radiate to the neck. No

diastolic murmurs.

Breasts: Pendulous, symmetric. No masses; nipples without discharge.
Abdomen: Protuberant. Well-healed scar, right lower quadrant. Bowel sounds
active. No tenderness or masses. Liver span 7 cm in right midclavicular line;

edge smooth, palpable 1 cm below right costal margin (RCM). Spleen and

kidneys not felt. No costovertebral angle tenderness (CVAT).

Genitalia: External genitalia without lesions. Mild cystocele at introitus on
straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge.

Uterus anterior, midline, smooth, not enlarged. Adnexa not palpated due to

obesity and poor relaxation. No cervical or adnexal tenderness. Pap smear

taken. Rectovaginal wall intact.

Rectal: Rectal vault without masses. Stool brown, negative for fecal blood.
Extremities: Warm and without edema. Calves supple, nontender.
Peripheral vascular: Trace edema at both ankles. Moderate varicosities of
saphenous veins both in lower extremities. No stasis pigmentation or ulcers.

Pulses (2+ = brisk, or normal):

Radial Femoral Popliteal
Dorsalis
Pedis

Posterior
Tibial

RT 2+ 2+ 2+ 2+ 2+
LT 2+ 2+ 2+ Absent 2+

Musculoskeletal: No joint deformities. Good range of motion in hands, wrists,
elbows, shoulders, spine, hips, knees, ankles.

Neurologic: Mental Status: Tense, but alert and cooperative. Thought coher-
ent. Oriented to person, place, and time. Cranial nerves: II to XII intact.
Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar:
RAMs, point-to-point movements intact. Gait stable, fluid. Sensory: Pinprick,
light touch, position sense, vibration, and stereognosis intact. Romberg

negative.

Reflexes:

Biceps Triceps
Brachio-
radialis Patellar Achilles Plantar

RT 2+ 2+ 2+ 2+ 1+ ↓
LT 2+ 2+ 2+ 2+/2+ 1+ ↓

See Muscle Strength Grading, p. 743.

Two methods for recording reflexes

may be used: a tabular form or a

stick picture diagram; 2+ = brisk, or
normal. See p. 758 for system for

grading reflexes.

(continued )

++
++

++
++

++

++ ++ ++
++

++++

++

+ +

_ _

OR

C H A P T E R 1 |

Foundations for Clinical Proficiency 35

THE QUALITY CLINICAL RECORD: THE CASE OF MRS. N.

The Case of Mrs. N. (continued )

ASSESSMENT AND PLAN
1. Migraine headaches: A 54-year-old woman with migraine headaches since

childhood, with a throbbing vascular pattern and frequent nausea and vomit-

ing. Headaches are associated with stress and relieved by sleep and cold

compresses. There is no papilledema, and there are no motor or sensory

deficits on the neurologic examination. The differential diagnosis includes

tension headache, also associated with stress, but there is no relief with

massage, and the pain is more throbbing than aching. There are no fever, stiff

neck, or focal findings to suggest meningitis, and the lifelong recurrent pat-

tern makes subarachnoid hemorrhage unlikely (usually described as

“the worst headache of my life”).

Plan:
● Discuss features of migraine versus tension headaches.
● Discuss biofeedback and stress management.
● Advise patient to avoid caffeine, including coffee, colas, and other carbon-

ated beverages.
● Start nonsteroidal anti-inflammatory drugs (NSAIDs) for headache, as

needed.
● If needed next visit, begin prophylactic medication if headaches are occur-

ring more than 2 days a week or 8 days a month.

2. Elevated blood pressure: Systolic hypertension is present. May be related
to anxiety from first visit. No evidence of end-organ damage to retina or

heart.

Plan:
● Discuss standards for assessing blood pressure.
● Recheck blood pressure in 1 month.
● Check basic metabolic panel; review urinalysis.
● Discuss weight reduction and exercise programs (see #4).
● Reduce salt intake.

3. Cystocele with occasional stress incontinence: Cystocele on pelvic exami-
nation, probably related to bladder relaxation. Patient is perimenopausal.

Incontinence reported with coughing, suggesting alteration in bladder neck

anatomy. No dysuria, fever, flank pain. Not taking any contributing medica-

tions. Usually involves small amounts of urine, no dribbling, so doubt urge or

overflow incontinence.

Plan:
● Explain cause of stress incontinence.
● Review urinalysis.
● Recommend Kegel exercises.
● Consider topical estrogen cream to vagina during next visit if no

improvement.

(continued )

36 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE QUALITY CLINICAL RECORD: THE CASE OF MRS. N.

The Case of Mrs. N. (continued )

4. Overweight: Patient 5′2″, weighs 143 lbs. BMI is ∼26.
Plan:

● Explore diet history, ask patient to keep food intake diary.
● Explore motivation to lose weight, set target for weight loss by next

visit.
● Schedule visit with dietitian.
● Discuss exercise program, specifically, walking 30 minutes most days a

week.

5. Family stress: Son-in-law with alcohol problem; daughter and grandchildren
seeking refuge in patient’s apartment, leading to tensions in these relation-

ships. Patient also has financial constraints. Stress currently situational. No

current evidence of major depression.

Plan:
● Explore patient’s views on strategies to cope with stress.
● Explore sources of support, including Al-Anon for daughter and finan-

cial counseling for patient.
● Continue to monitor for depression.

6. Occasional musculoskeletal low back pain: Usually with prolonged stand-
ing. No history of trauma or motor vehicle accident. Pain does not radiate;

no tenderness or motor-sensory deficits on examination. Doubt disc or nerve

root compression, trochanteric bursitis, sacroiliitis.

Plan:
● Review benefits of weight loss and exercises to strengthen low back

muscles.

7. Tobacco abuse: 1 pack per day for 36 years.
Plan:

● Check peak flow or FEV1/FVC on office spirometry.
● Give strong warning to stop smoking.
● Offer referral to tobacco cessation program.
● Offer patch, current treatment to enhance abstinence.

8. Varicose veins, lower extremities: No complaints currently.
9. History of right pyelonephritis: 1998.
10. Ampicillin allergy: Developed rash, but no other allergic reaction.
11. Health maintenance: Last Pap smear 2014; has never had a mammogram.
Plan:

● Schedule mammogram.
● Pap smear sent today.
● Provide three cards to test for fecal blood; next visit, discuss screening

colonoscopy.
● Suggest dental care for mild gingivitis.
● Advise patient to move medications and caustic cleaning agents to locked

cabinet above shoulder height. Urge patient to move gun and cartridges

to a locked gun cabinet.

See Chapter 3, Interviewing and the

Health History, section on Motivational

Interviewing, p. 81, and Table 3-1,

Motivational Interviewing: A Clinical

Example, p. 104.

C H A P T E R 1 |

Foundations for Clinical Proficiency 37

THE QUALITY CLINICAL RECORD: THE CASE OF MRS. N.

The Importance of the Problem List

After you complete the clinical record, it is good clinical practice to generate a
Problem List that summarizes the patient’s problems that can be placed in the
front of the office or hospital chart. List the most active and serious problems first,
and record their date of onset. Some clinicians make separate lists for active or inac-
tive problems; others make one list in order of priority. A good Problem List helps
you to individualize the patient’s care. On follow-up visits, the Problem List pro-
vides a quick summary of the patient’s clinical history and a reminder to review
the status of problems the patient may not mention. An accurate Problem List
allows better population management of patients, by using EHRs to track patients
with specific problems, recall patients who are behind on appointments, and
follow up on specific issues. The Problem List also allows other members of the
health care team to learn about the patient’s health status at a glance.

A sample Problem List for Mrs. N. is provided below. You may wish to number each
problem and use the number to refer to specific problems in subsequent notes.

Clinicians organize problem lists differently, even for the same patient. Problems
can be symptoms, signs, past health events such as a hospital admission or surgery,
or diagnoses. You might choose different entries from those above. Good lists vary
in emphasis, length, and detail, depending on the clinician’s philosophy, specialty,
and role as a provider. Some clinicians would find this list too long. Others would
be more explicit about “family stress” or “varicose veins.”

Problem List: The Case of Mrs. N.

Date Problem No. Problem

8/25/16 1

2

3

4

5

6

7

8

9

10

11

Migraine headaches

Elevated blood pressure

Cystocele with occasional stress

incontinence

Overweight

Family stress

Low back pain

Tobacco abuse since age 18 years

Varicose veins

History of right pyelonephritis: 1998

Allergy to ampicillin

Health maintenance

The list illustrated here includes problems that need attention now, like Mrs. N.’s
headaches, as well as problems that need future observation and attention, such
as her blood pressure and cystocele. Listing the allergy to ampicillin reminds you
not to prescribe medications in the penicillin family. Some symptoms such as
canker sores and hard stools do not appear on this list because they are minor
concerns and do not require attention during this visit. Problem lists with too
many relatively insignificant items are distracting. If these symptoms increase in
importance, they can be added at a later visit.

38 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

RECORDING YOUR FINDINGS

Checklist to Ensure a Quality Clinical Record

Is the Order Clear?
Order is imperative. Make sure that readers can easily find specific points of

information. Keep the subjective items of the history, for example, in the
history; do not let them stray into the physical examination. Did you:

● Make the headings clear?
● Accent your organization with indentations and spacing?
● Arrange the Present Illness in chronologic order, starting with the current

episode, then filling in relevant background information?

Do the Data Included Contribute Directly to the Assessment?
Spell out the supporting evidence, both positive and negative, for each problem

or diagnosis. Make sure there is sufficient detail to support your differential

diagnosis and plan.

Are Pertinent Negatives Specifically Described?
Often, portions of the history or examination suggest that an abnormality might

exist or develop in that area. For example, for the patient with notable bruises,

record the “pertinent negatives,” such as the absence of injury or violence,

familial bleeding disorders, or medications or nutritional deficits that might lead

to bruising. For the patient who is depressed but not suicidal, recording both

facts is important. In the patient with a transient mood swing, on the other

hand, a comment on suicide is unnecessary.

Are There Overgeneralizations or Omissions of Important Data?
Remember that data not recorded are data lost. No matter how vividly you can
recall clinical details today, you will probably not remember them in a few

months. The phrase “neurologic exam negative,” even in your own handwrit-

ing, may leave you wondering in a few months’ time, “Did I really check the

reflexes?”

A clear, well-organized clinical record is one of the most important adjuncts to
patient care. Your goal is a clear, concise, but comprehensive report that docu-
ments key findings and communicates your assessment in a succinct and legible
format to clinicians, consultants, and other members of the health care team.

Regardless of your experience, adopting certain principles will help you organize
a good record. Think especially about the order and readability of the record and
the amount of detail needed. How much detail to include often varies at different
points in training. As a student, you may wish (or be required) to be quite
detailed. This builds your descriptive skills, vocabulary, and speed. Later, the
pressures of workload and time management will lead to less but more focused
detail. A good record always provides sufficient evidence from the history, phys-
ical examination, and laboratory findings to support all the problems or diagno-
ses identified.

(continued )

Recording Your Findings

C H A P T E R 1 |

Foundations for Clinical Proficiency 39

RECORDING YOUR FINDINGS

Checklist to Ensure a Quality
Clinical Record (continued )

Is There Too Much Detail?
Is there excess information or redundancy? Is important information buried in a

mass of detail, to be discovered by only the most persistent reader? Make your

descriptions concise. “Cervix pink and smooth” indicates you saw no redness,

ulcers, nodules, masses, cysts, or other suspicious lesions, but this description is

shorter and more easily read. You can omit unimportant structures even though

you examined them, such as normal eyebrows and eyelashes.

Omit most of your negative findings unless they relate directly to the patient’s
complaints or specific exclusions in your differential diagnosis. Instead, concen-
trate on major negative findings such as “no heart murmurs.”

Is the Written Style Succinct? Are Phrases, Short Words, and Abbreviations
Used Appropriately? Is Data Unnecessarily Repeated?
Omit repetitive introductory phrases such as “The patient reports no . . . ”

because readers assume the patient is the source of the history unless other-

wise specified.

● Using words or brief phrases instead of whole sentences is common, but

abbreviations and symbols should be used only if they are readily understood.

Use shorter words when possible such as “felt” for “palpated” or “heard” for

“auscultated.” Omit unnecessary words, such as those in parentheses in the

examples below. This saves valuable time and space. For example, “Cervix is

pink (in color).” “Lungs are resonant (to percussion).” “Liver is tender (to pal-

pation).” “Both (right and left) ears with cerumen.” “II/IV systolic ejection

murmur (audible).” “Thorax symmetric (bilaterally).”
● Describe what you observed, not what you did. “Optic discs seen” is less

informative than “disc margins sharp.”

Are Diagrams and Precise Measurements Included Where Appropriate?

Diagrams add greatly to the clarity of the record.

(continued )

40 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

RECORDING YOUR FINDINGS

Checklist to Ensure a Quality
Clinical Record (continued )

To ensure accurate evaluations and future comparisons, make measurements

in centimeters, not in fruits, nuts, or vegetables.

● “1 × 1 cm lymph node” versus a “pea-sized lymph node . . .”
● Or “2 × 2 cm mass on the left lobe of the prostate” versus a “walnut-sized

prostate mass.”

Is the Tone of the Write-up Neutral and Professional?
It is important to be objective. Hostile or disapproving comments have no

place in the patient’s record. Never use inflammatory or demeaning words or

punctuation.

Comments such as “Patient DRUNK and LATE TO CLINIC AGAIN!!” are

unprofessional and set a bad example for other clinicians reading the chart.

They also might prove difficult to defend in a legal setting.

C H A P T E R 1 |

Foundations for Clinical Proficiency 41

A month later, Mrs. N. returns for a follow-up visit. The format of the office or hospital progress note is quite variable, but it should
meet the same standards as the initial assessment. The note should be clear, sufficiently detailed, and easy to follow. It should reflect
your clinical reasoning and delineate your assessment and plan. Be sure to learn the documentation standards for billing in your
institution, because this can affect the detail and type of information needed in your progress notes.

The note below follows the SOAP format: Subjective, Objective, Assessment, and Plan. You will see many other styles, some focused
on the “patient-centered” record.49 The four categories of the SOAP note are often implied and not spelled out, as in the note below.

9/25/16

Mrs. N. returns for follow-up of her migraine headaches. She
has had fewer headaches since reducing her intake of caffeine.
She is now drinking decaffeinated coffee and has stopped drink-
ing tea. She has joined a support group and started exercising to
reduce stress. She is still having one to two headaches a month
with some nausea, but they are less severe and generally relieved
with NSAIDs. She denies any fever, stiff neck, associated visual
changes, motor-sensory deficits, or paresthesias.

She has been checking her blood pressure at home. It is run-
ning about 150/90. She is walking 30 minutes three times a
week in her neighborhood and has reduced her daily caloric
intake. She has been unable to stop smoking. She has been
doing the Kegel exercises, but still has some leakage with cough-
ing or laughing.

Medications: Motrin 400 mg up to three times daily as needed for
headache.

Allergies: Ampicillin causes rash.
Tobacco: 1 pack per day since age 18 years.

Physical Examination: Pleasant, overweight, middle-aged
woman, who is animated and somewhat tense. Ht 157 cm (5′
2″). Wt 63 kg (140 lbs). BMI 26. BP 150/90. HR 86 and regular.
RR 16. Afebrile.

Skin: No suspicious nevi. HEENT: Normocephalic, atrau-
matic. Pharynx without exudates. Neck: Supple, without thyro-
megaly. Lymph nodes: No lymphadenopathy. Lungs: Resonant
and clear. CV: JVP 6 cm above the right atrium; carotid up-
strokes brisk, no bruits. Good S1, S2. No murmurs heard today.
No S3, S4. Abdomen: Active bowel sounds. Soft, nontender, no
hepatosplenomegaly. Extremities: Without edema.

Labs: Basic metabolic panel and urinalysis from 8/25/16 un-
remarkable. Pap smear normal.

Impression and Plan

1. Migraine headaches—now down to one to two per month
due to reductions in caffeinated beverages and stress.
Headaches are responding to NSAIDs.
â–  Will defer daily prophylactic medication for now because

patient is having fewer than three headaches per month
and feels better.

â–  Affirm need to stop smoking and to continue exercise
program.

■ Affirm patient’s participation in support group to reduce
stress.

2. Elevated blood pressure—BP remains elevated at 150/90.
â–  Will initiate therapy with a diuretic.
â–  Patient to take blood pressure three times a week at home

and bring recordings to next office visit.
3. Cystocele with occasional stress incontinence—stress incon-

tinence improved with Kegel exercises but still with some
urine leakage. Urinalysis from last visit—no infection.
â–  Initiate vaginal estrogen cream.
â–  Continue Kegel exercises.

4. Overweight—has lost ∼4 lbs.
â–  Continue exercise.
â–  Review diet history; affirm weight reduction.

5. Family stress—patient handling this better. See Plans above.
6. Occasional low back pain—no complaints today.
7. Tobacco abuse—see Plans above. Will start medication.
8. Health maintenance—Pap smear sent last visit. Mammogram

scheduled. Colonoscopy recommended.

Table 1-1 Sample Progress Note

42 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

REFERENCES

References
1. Verghese A, Horwitz RI. In praise of the physical examination. BMJ.

2009;339:b5448.
2. U.S. Preventive Services Task Force. Guide to Clinical Preventive

Services 2014. Recommendations of the U.S. Preventive Services
Task Force. June 2014. Available at http://www.ahrq.gov/profes-
sionals/clinicians-providers/guidelines-recommendations/guide/.
See also U.S. Preventive Services Task Force: Recommendations for
Primary Care Practice. December 2013. Available at http://www.
uspreventiveservicestaskforce.org/Page/Name/recommendations
Accessed February 27, 2015.

3. Sussman J, Beyth RJ. Society of General Internal Medicine, Choos-
ing Wisely: Five Things Physicians and Patients Should Question,
Don’t Perform Routine General Health Checks for Asymptomatic
Adults. ABIM Foundations Choosing Wisely Campaign Published
online http://www.choosingwisely.org/doctor-patient-lists/society-
of-general-internal-medicine/, 2013. Available at https://www.
google.com/#q=Society+of+general+internal+medicine+-+
choosing+wisely+Sussman+Beyth. Accessed March 18, 2015.

4. Krogsboll LT, Jorgensen KJ, Gronhoj Larsen C, et al. General health
checks in adults for reducing morbidity and mortality from
disease: Cochrane systematic review and meta-analysis. BMJ.
2012;345:e7191.

5. Chacko KM, Anderson RJ. The annual physical examination:
important or time to abandon? Am J Med. 2007;120:581.

6. Boulware LE, Marinopoulos S, Phillips KA, et al. Systematic review:
the value of the periodic health evaluation. Ann Intern Med. 2007;
146:289.

7. Culica D, Rohrer J, Ward M, et al. Medical check-ups: who does
not get them. Am J Public Health. 2002;92:88.

8. Laine C. The annual physical examination: needless ritual or nec-
essary routine? Ann Intern Med. 2002;136:701.

9. Oboler SK, Prochazka AV, Gonzales R, et al. Public expectations
and attitudes for annual physical examinations and testing. Ann
Intern Med. 2002;136:652.

10. Hesrud DD. Clinical preventive medicine in primary care: back-
ground and practice. Rational and current preventive practice.
Mayo Clin Proc. 2000;75:165.

11. Mookherjee S, Pheatt MA, Ranji SR, et al. Physical examination
education in graduate medical education—a systematic review of
the literature. J Gen Int Med. 2013;28:1090.

12. Reilly BM. Physical examination in the care of medical inpatients:
an observational study. Lancet. 2003;362:1100.

13. Simel DL, Rennie D. The clinical examination. An agenda to make
it more rational. JAMA. 1997;277:572.

14. Sackett DL. A primer on the precision and accuracy of the clinical
examination. JAMA. 1992;267:2638.

15. Evidence-Based Working Group. Evidence-based medicine. A new
approach to teaching the practice of medicine. JAMA. 1992;268:2420.

16. Herrie SR, Corbett EC, Fagan MJ, et al. Bayes’ theorem and the
physical examination: probability assessment and diagnostic
decision-making. Acad Med. 2011;85:618.

17. McGee S. Evidence-based Physical Diagnosis. 3rd ed. Philadelphia,
PA: Elsevier Saunders; 2012.

18. Smith MA, Burton WM, Mackay M. Development, impact, and
measurement of enhanced physical diagnosis skills. Adv Health Sci
Educ Theory Pract. 2009;14:547.

19. Centers for Disease Control and Prevention (CDC). Standard
precautions. Guidelines for isolation precautions: preventing
transmission of infectious agents in healthcare settings 2007.
Updated October 2007. Available at http://www.cdc.gov/hicpac/
2007IP/007isolationPrecautions.html. Accessed March 1, 2015.

20. Centers for Disease Control and Prevention. Guide to infection
prevention in outpatient settings. Minimum expectations for safe
care. May 2011. Available at http://www.cdc.gov/HAI/settings/
outpatient/outpatient-care-guidelines.html. Accessed March 1,
2015.

21. Centers for Disease Control and Prevention. Hand Hygiene in
Healthcare Settings. Updated January 2015. At http://www.cdc.
gov/handhygiene/. Accessed March 1, 2015.

22. Centers for Disease Control and Prevention. Precautions to prevent
the spread of MRSA in healthcare settings. Updated September
2014. Available at http://www.cdc.gov/mrsa/healthcare/clinicians/
precautions.html. Accessed March 1, 2015.

23. Centers for Disease Control and Prevention. Bloodborne infectious
diseases: HIV/AIDS, Hepatitis B, Hepatitis C. Universal precau-
tions for the prevention for transmission of bloodborne infections,
p. 66. Updated December 2011. Available at http://www.cdc.gov/
niosh/topics/bbp/universal.html. Accessed March 1, 2105.

24. Bearman G, Bryant K, Leekha S, et al. Healthcare personnel attire
in non-operating-room settings. Infect Control Hosp Epidemiol.
2014;35:107.

25. Treakle AM, Thom KA, Furuno JP, et al. Bacterial contamination
of health care workers’ white coats. Am J Infect Control. 2009;
37:101.

26. Peterson MC, Holbrook JH, Von Hales DE, et al. Contributions of
the history, physical examination, and laboratory investigation in
making medical diagnoses. West J Med. 1992;156:163.

27. Hampton JR, Harrison MJ, Mitchell JR, et al. Relative contributions
of history-taking, physical examination, and laboratory investiga-
tion to diagnosis and management of medical outpatients. Br Med
J. 1975;2(5969):486.

28. Kassirer JP. Teaching clinical reasoning: case-based and coached.
Acad Med. 2010;85:1118.

29. Kassirer J, Wong J, Kopelman R. Learning Clinical Reasoning.
2nd ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams
& Wilkins; 2010.

30. Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med
Educ. 2010;44:94.

31. Bowen J. Educational strategies to promote clinical diagnostic rea-
soning. New Engl J Med. 2006;355:2217.

32. Coderre S, Mandin H, Harasym P, et al. Diagnostic reasoning strat-
egies and diagnostic success. Med Educ. 2003;37:695.

33. Elstein A, Schwarz A. Clinical problem solving and diagnosis deci-
sion making: selective review of the cognitive literature. Br Med J.
2002;324(7339):729.

34. Norman G. Research in clinical reasoning: past history and current
trends. Med Educ. 2005;39:418.

35. Schneiderman H, Peixoto AJ. Bedside Diagnosis. An Annotated Bibli-
ography of Literature on Physical Examination and Interviewing, 3rd ed.
Philadelphia, PA: American College of Physicians; 1997.

36. Simel DL, Rennie D. The Rational Clinical Examination: Evidence-
Based Clinical Diagnosis. New York: McGraw Hill; 2009.

C H A P T E R 1 |

Foundations for Clinical Proficiency 43

REFERENCES

37. Guyatt G, Rennie D, Meade M. Users’ Guide to the Medical Litera-
ture: A Manual for Evidence-Based Clinical Practice. New York:
McGraw-Hill Medical; 2008.

38. Fletcher RH, Fletcher SW, Fletcher G. Clinical Epidemiology: The Essen-
tials. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.

39. Sackett DL. Evidence-based Medicine: How to Practice and Teach
EBM. 2nd ed. New York: Churchill Livingstone; 2000.

40. Montiero SM, Norman G. Diagnostic reasoning: where we’ve been,
where we’re going. Teach Learn Med. 2013;25(Suppl 1):S26.

41. Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic
errors. Acad Med. 2011;86:307.

42. Reilly JB, Odgie AR, Von Feldt JM, et al. Teaching about how doc-
tors think: a longitudinal curriculum in cognitive bias and diag-
nostic error for residents. BMJ Qual Saf. 2013;22:1044.

43. Dubeau CE, Voytovich AE, Rippey RM. Premature conclusions in
the diagnosis of iron-deficiency anemia: cause and effect. Med
Decis Making. 1986;6:169.

44. Kuhn GJ. Diagnostic errors. Acad Emerg Med. 2002;9:740.
45. Graber ML, Franklin N, Gordon R. Diagnostic error in internal

medicine. Arch Intern Med. 2005;165:1493.
46. Redelmeier DA. Improving patient care: the cognitive psychology

of missed diagnoses. Ann Intern Med. 2005;142:115.
47. Berner ES, Graber ML. Overconfidence as a cause of diagnostic

error in medicine. Am J Med. 2008;121:S2.
48. Newman-Toker DE, Pronovost PJ. Diagnostic errors—the next

frontier for patient safety. JAMA. 2009;301:1060.
49. Donnelly WJ. Viewpoint: patient-centered medical care requires a

patient-centered medical record. Acad Med. 2005;80:33.

C H A P T E R 2 |

Evaluating Clinical Evidence 45

Excellence in clinical care requires integrating clinical expertise, patient prefer-
ences, and the best available clinical evidence.1

Carefully study the clear descriptions of how the history and physical examina-
tion can be viewed as diagnostic tests; how to assess the accuracy of laboratory
tests, radiographic imaging, and diagnostic procedures; and how to evaluate
clinical research studies and disease prevention guidelines. Mastering these ana-
lytic skills will improve your clinical practice and ensure that your assessments
and recommendations are based on the best clinical evidence (Fig. 2-1).

C H A P T E R

2
Evaluating Clinical Evidence

The Bates’ suite offers these additional resources to enhance learning and facilitate
understanding of this chapter:
■ Bates’ Pocket Guide to Physical Examination and History Taking, 8th edition
■ Bates’ Visual Guide to Physical Examination (All Volumes)
â–  thePoint online resources, for students and instructors: http://thepoint.lww.com

Clinical
expertise

Patient
preferences

Research
evidence

F I G U R E 2 – 1 . Evidence-based clinical practice Venn diagram. (Adapted with permission from
Haynes RB, Sackett DL, Gray JM, et al. Transferring evidence from research into practice: 1. The role of clinical care research

evidence in clinical decisions. ACP J Club. 1996;125:A14–A16.)

THE HISTORY AND PHYSICAL EXAMINATION AS DIAGNOSTIC TESTS

46 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

You will develop your clinical expertise as you learn about and practice your
clinical discipline, enabling you to more efficiently make diagnoses and identify
potential interventions. Chapter 3 addresses strategies for engaging patients in
health care decisions, recognizing that patients bring individualized preferences,
concerns, and expectations to the clinical encounter. Elements of the history and
physical examination can be considered diagnostic tests, whose accuracy can be
evaluated according to criteria presented later in this chapter. Throughout the
regional examination chapters, you will find evidence-based recommendations
for health promotion interventions, especially screening and prevention. These
recommendations are also based on evidence from the clinical literature that can
be evaluated according to criteria presented in this chapter.

Test
Threshold0%

Probability of Diagnosis

Probability below
test threshold;

no testing warranted

Treatment
Threshold 100%

Probability between
test and treatment threshold;

further testing required

Probability above treatment
threshold; testing completed;

treatment commences

F I G U R E 2 – 2 . Probability revisions. (Adapted with permission from Guyatt G, Rennie D, Meade M, et al.
Users’ Guides to the Medical Literature. 2nd ed. New York, NY: McGraw-Hill Company; 2008; Chapter 14, Figure 14-2.)

The History and Physical
Examination as Diagnostic
Tests

The process of diagnostic reasoning begins with the history. As you learn about
your patient, you will start to develop a differential diagnosis. This is a list of
potential causes for the patient’s problems and the length of the list will reflect
your uncertainty about the possible explanation for a given problem. Your list
will start with the most likely explanation, but will also include other plausible
diagnoses, particularly those that have serious consequences if undiagnosed and
untreated. You will assign probabilities to the various diagnoses that correspond
to how likely you consider them to be explanations for your patient’s problem.
For now, these probabilities will be based on what you have learned from text-
books and lectures. In time, these probability estimates will also reflect your
clinical experience.

When you begin approaching clinical problems your goal is to determine
whether you need to perform additional testing (Fig. 2-2).2

EVALUATING DIAGNOSTIC TESTS

C H A P T E R 2 |

Evaluating Clinical Evidence 47

If your probability for a disease based on your history and examination is very
high (i.e., exceeds the treatment threshold), then you can move ahead and
initiate treatment. Conversely, if your probability for a disease is very low (i.e.,
below the test threshold), then you do not need further testing. The area
between the test and treatment thresholds represents clinical uncertainty, and
you need further testing to revise probabilities and guide your clinical man-
agement. The expectation is that test results will enable you to cross a test-
treatment threshold. You should understand that these test-treatment
thresholds are not set in stone and will vary based on the potential adverse
effects of the treatment and the seriousness of the condition. For example, you
will require a much higher treatment threshold (confidence that the patient
has a high probability of having the disease) for initiating cancer chemother-
apy compared to prescribing an antibiotic for a urinary tract infection. You
would require a much lower test threshold (confidence that the patient has a
low probability of having the disease) when excluding ischemic heart disease
than bacterial sinusitis. However, knowing whether a test result will achieve
that effect can be challenging and requires you to understand how to evaluate
the performance of a diagnostic test.

Evaluating Diagnostic Tests
You can turn to the clinical literature to determine how results from diagnostic
tests—which include elements of the clinical history and physical examina-
tion, as well as laboratory tests, radiographic imaging, and procedures—can be
used to revise probabilities. Two concepts in evaluating diagnostic tests will be
explored: the validity of the findings and the reproducibility of the test results.

Validity

The initial step in evaluating a diagnostic test is to determine whether it provides
valid results. Does the test accurately identify whether a patient has a disease? This
involves comparing the test against a gold standard—the best measure of whether
a patient has disease. This could be a biopsy to evaluate a lung nodule, a struc-
tured psychiatric examination to evaluate a patient for depression, or a colonos-
copy to evaluate a patient with a positive stool blood test.

The 2 × 2 table is the basic format for evaluating the performance characteristics
of a diagnostic test, which means how much the test results revise probabilities
for disease.

There are two columns—patients with disease present and patients with dis-
ease absent. These categorizations are based on the gold standard test. The two
rows correspond to positive and negative test results. The four cells (a, b, c, d)
correspond to true positives, false positives, false negatives, and true negatives,
respectively.3

EVALUATING DIAGNOSTIC TESTS

48 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

Sensitivity and Specificity. The first test statistics to estimate are sensitivity
and specificity.

Sensitivity and Specificity

● Sensitivity is the probability that a person with disease has a positive test.
This is represented as a/(a + c) in the disease present column of the 2 × 2
table. Sensitivity is also known as the true positive rate.

● Specificity is the probability that a non-diseased person has a negative test,
represented as d/(b + d) in the disease absent column of the 2 × 2 table.
Specificity is also known as the true negative rate.

● Examples. An example of these statistics would be the probability that spleno-
megaly (see Chapter 11, p. 479) is associated with percussion dullness below

the left costal margin (sensitivity). Conversely, the probability that a patient

without splenomegaly will have percussion dullness is the false positive rate

(1 − specificity) for this physical maneuver.

Setting up the 2 ¥ 2 Table

Gold Standard:
Disease Present

Gold Standard:
Disease Absent

Test positive a

True positive

b

False positive

Test negative c

False negative

d

True negative

Knowing the sensitivity and specificity of a test does not necessarily help you
make clinical decisions because they are statistics based on knowing whether the
patient has disease. However, there are two exceptions. A negative result from a
test with a high sensitivity (i.e., a very low false-negative rate) usually excludes
disease. This is represented by the acronym SnNOUT—a Sensitive test with a
Negative result rules OUT disease. Conversely, a positive result in a test with
high specificity (e.g., a very low false-positive rate) usually indicates disease.
This is represented by the acronym SpPIN—a Specific test with a Positive
result rules IN disease.4

Positive and Negative Predictive Values. The typical clinical scenario
faced by clinicians involves determining whether a patient actually has disease
based on a test result that is either positive or negative. The relevant test statis-
tics here are the positive and negative predictive values.3

EVALUATING DIAGNOSTIC TESTS

C H A P T E R 2 |

Evaluating Clinical Evidence 49

Prevalence of Disease. Although the predictive value statistics seem intu-
itively useful, they will vary substantially according to the prevalence of disease
(i.e., the proportion of patients in the disease present column). The prevalence
is based on the characteristics of the patient population and the clinical setting.
For example, the prevalence of many diseases will usually be higher among
older patients and among patients being seen in specialist clinics or at referral
hospitals.

The box below shows a 2 × 2 table where both the sensitivity and specificity of
the diagnostic test are 90% and the prevalence (proportion of subjects that
have the disease) is 10%. The positive predictive value calculated from the test
positive row of the table would be 90/180 = 50%. This means that half of the
people with a positive test have disease.

Positive and Negative Predictive Values

● The positive predictive value (PPV) is the probability that a person with a
positive test has disease, represented as a/(a + b) from the test positive row
in the 2 × 2 table.

An example of this statistic is found in prostate cancer screening (see

Chapter 15, p. 612), where a man with a PSA value greater than 4.0 ng/mL

has only a 30% probability of having prostate cancer found on biopsy.5

● The negative predictive value (NPV) is the probability that a person with a
negative test does not have disease, represented as d/(c + d) in the test nega-
tive row in the 2 × 2 table.

Among men with a PSA level of 4.0 ng/mL or below, 85% are found to be

cancer-free on biopsy.6

Predictive Values: Prevalence of 10% with
Sensitivity and Specificity = 90%

Disease Present Disease Absent Total

Test positive a

90

b

90 180

Test negative c

10

d

810 820

Total 100 900 1,000

However, if the sensitivity and specificity remained the same, but prevalence was
only 1%, then the cells would look very different.

Sensitivity = a/(a + c) = 90/100 or 90%; specificity = d /(b + d) = 810/900 = 90%

Positive predictive value = a/(a + b) = 90/180 = 50%

EVALUATING DIAGNOSTIC TESTS

50 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

Now the positive predictive value calculated from the test positive row of the
table would be 9/108 = 8.3%. The consequence is that the great majority of
positive tests are false positives—meaning that most of the subjects who undergo
gold standard tests (which are usually invasive, expensive, and potentially harm-
ful) will not have disease. This has implications for patient safety and resource
allocation because clinicians want to limit the number of non-diseased patients
who undergo gold standard tests. However, as shown by the example, predictive
values will not necessarily provide us with sufficient guidance for using tests
across populations with differing disease prevalence.

Likelihood Ratios. Fortunately, there are other ways to evaluate the perfor-
mance of a diagnostic test that can account for the varying disease prevalence
observed in different patient populations. One way uses likelihood ratio statis-
tics, defined as the probability of obtaining a given test result in a diseased
patient divided by the probability of obtaining a given test result in a non-
diseased patient.3,7 The likelihood ratio tells us how much a test result changes
the pre-test disease probability (prevalence) to the post-test disease probability.

In the simplest case, we will assume that the test result is either positive or nega-
tive. Therefore, the likelihood ratio for a positive test is the ratio of getting a positive
test result in a diseased person divided by the probability of getting a positive test
result in a non-diseased person. From the 2 × 2 table, we see that this is the same
as saying the ratio of the true positive rate (sensitivity) over the false positive rate
(1 − specificity). A higher value (much >1) indicates that a positive test is much
more likely to be coming from a diseased person than from a non-diseased per-
son, increasing our confidence 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 non-diseased person.7 From the 2 × 2 table, we see that
this is the same as saying the ratio of the false negative rate (1 − sensitivity)
divided by the true negative rate (specificity). A lower value (much <1) indi-
cates that the negative test is much more likely to be coming from a non-
diseased person than from a diseased person, increasing our confidence that a
person with a negative result does not have disease.

Predictive Values: Prevalence of 1% with
Sensitivity and Specificity = 90%

Disease Present Disease Absent Total

Test positive a

9

b

99 108

Test negative c

1

d

891 892

Total 10 990 1,000

Sensitivity = a/(a + c) = 9/10 or 90%; specificity = d /(b + d) = 891/990 = 90%

Positive predictive value = a/(a + b) = 9/108 = 8.3%

EVALUATING DIAGNOSTIC TESTS

C H A P T E R 2 |

Evaluating Clinical Evidence 51

The box below shows how to interpret likelihood ratios based on how much a
test result changes the pre- to post-test probabilities for disease.8

Interpreting Likelihood Ratios

Likelihood Ratiosa Effect on Pre- to Post-Test Probability

LRs > 10 or < 0.1 Generate large changes
LRs 5–10 or 0.1–0.2 Generate moderate changes

LRs 2–5 and 0.5–0.2 Generate small (sometimes important) changes

LRs 1–2 and 0.5–1 Alter the probability to a small degree (rarely

important)

aLikelihood ratios >1 are associated with positive results and an increased probability for disease.
Likelihood ratios <1 are associated with negative results and a decreased probability of disease. A test
with a likelihood ratio of 1 provides no additional information about the probability of disease.

We will show how likelihood ratios can be used to revise probabilities for disease
with the example of breast cancer screening.

How Likely Is It That a Woman with Abnormal
Mammogram Has Breast Cancer?

A 57-year-old woman at average risk for breast cancer has an abnormal mammo-

gram. She wants to know the probability that she has breast cancer. The literature

states that the baseline risk (prevalence) is 1%, the sensitivity of mammography is

90%, and the specificity is 91%.

Bayes Theorem. One way to use likelihood ratios to revise probabilities for
disease is with the Bayes theorem.4 This theorem requires converting the esti-
mated prevalence (pre-test probability) to odds using the equation:

Pre-test odds = pre-test probability/(1 − pre-test probability)

The pre-test odds are multiplied by the likelihood ratio to estimate the post-test
odds using the following equation:

Post-test odds = pre-test odds × likelihood ratio

The post-test odds are then converted to a probability using the equation:

Post-test probability = post-test odds/(1 + post-test odds)

For the example, the 1% prevalence represents the pre-test probability; this
means that the pre-test odds are 0.01/0.99 or 0.01. The likelihood ratio for a
positive test is sensitivity/(1 − specificity), which is 90%/9% = 10. The pre-test

EVALUATING DIAGNOSTIC TESTS

52 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

odds are multiplied by this likelihood ratio (0.01 × 10) to give post-test odds of
0.10. The post-test odds are converted [0.1/(1 + 0.1)] to a post-test probability
of about 9%.

Fagan Nomogram. If you are more comfortable thinking in terms of proba-
bility of having disease, then the Fagan nomogram may be an easier way for you
to use likelihood ratios (Fig. 2-3).9 With this nomogram, you read the pre-test
probabilities from the line on the left, then take a straight edge and draw a line
from the pre-test probability through the likelihood ratio in the middle line, and
then read the post-test probability on the line on the right.

You can also use the Fagan nomogram to answer the mammography question
(Fig 2-3). The pre-test probability (prevalence) = 1% and the likelihood for a

2000
1000

500

200

100

50

20

10

5

2

1

0.002

0.005
0.01

0.02

0.05
0.1

0.2

0.5

0.001

0.0005

0.1

Pre-test
Probability (%)

Likelihood
Ratio

0.2

0.5

1

2

5

10

20

30

40

50

60

70

80

90

95

98

99 0.1

0.2

0.5

1

2

5

10

20

30

40

50

60

70

80

90

95

98

99

Post-test
Probability (%)

F I G U R E 2 – 3 . Fagan nomogram. (Adapted with permission from Fagan TJ. Letter: nomogram for Bayes
theorem. N Engl J Med. 1975;293:257.)

EVALUATING DIAGNOSTIC TESTS

C H A P T E R 2 |

Evaluating Clinical Evidence 53

positive test [sensitivity/(1 − specificity)] = 10. The blue line corresponds to the
case of a positive test with a post-test probability of about 9%. If the mammogram
result was negative (red line), then the likelihood ratio for a negative test
[(1 − sensitivity)/specificity] would be 10%/91% = 0.11 and the post-test prob-
ability for breast cancer would be 0.1%.

Natural Frequencies. Using frequency statements is another, perhaps more
intuitive, alternative to likelihood ratios for determining how a test result will
change the probability of disease.9,10 Natural frequencies represent the joint
frequency of two events, such as the number of patients with disease and the
number who have a positive test result. Start by taking a large number of
people (e.g., 100 or 1,000, depending upon the prevalence) and break the
number down into natural frequencies (i.e., how many of the people have
disease, how many with disease will test positive, how many without disease
will test positive).

Natural Frequencies to Answer the
Mammography Question

We can use natural frequencies to answer the mammography question by creat-

ing a 2 × 2 table based on a population of 1,000 women. The 1% prevalence
means that 10 women will have breast cancer. The sensitivity of 90% means that

9 of the women with breast cancer will have an abnormal mammogram. The

specificity of 91% means that 89 of the 990 women without breast cancer will

still have an abnormal mammogram. The probability that a woman with an

abnormal mammogram will have breast cancer is 9/(9 + 89) = about 9%.

Mammogram
Result

Breast
Cancer

No Breast
Cancer Total

Positive 9 89 98

Negative 1 901 902

10 990 1,000

Data compiled from Gigerenzer G. What are natural frequencies? BMJ. 2011;343:d6386.

Reproducibility

Kappa Score. Another characteristic of a diagnostic test is reproducibility.3
An important aspect of evaluating diagnostic elements of the history or physi-
cal examination is determining the reproducibility of the findings for diagnos-
ing a clinical disorder. When, for example, two clinicians examine a patient,
they may not always agree upon the presence of a given finding. This raises the
question of whether this finding is useful for diagnosing a clinical disorder.
By chance, if many patients are being examined, there will be a certain amount
of agreement between the two clinicians. Understanding whether there is
agreement well beyond chance, though, is important in knowing whether the

EVALUATING DIAGNOSTIC TESTS

54 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

finding is useful enough to support clinical decision making. The kappa score
measures the amount of agreement that occurs beyond chance (Fig. 2-4).12 The
box shows how to interpret Kappa values.

Understanding Measure of Agreement between Different Observ-
ers. The clinicians agree 75% of the time that a patient has an abnormal phys-
ical finding. The expected agreement based on chance is 50%. This means that
the potential agreement beyond chance is 50% and the actual observer agree-
ment beyond chance is 25%. The kappa level is then 25%/50% = 0.5, which
indicates moderate agreement.

Precision. In the context of reproducibility, precision refers to being able to
apply the same test to the same unchanged person and obtain the same results.4
Precision is often used when referring to laboratory tests. For example, when
measuring a troponin level for cardiac ischemia, clinicians might use a particu-
lar cutoff level to decide whether to admit a patient to a coronary care unit. If
the test results are imprecise, this could lead to admitting a patient without

Agreement expected by chance Possible agreement above chance

75%
25%

50%

Observed agreement:
Observed agreement above chance:

kappa = 25/50 = 0.5 (moderate agreement)

F I G U R E 2 – 4 . Kappa scores. (Adapted with permission from McGinn T, Wyer PC, Newman TB, et al. Tips for
learners of evidence-based medicine: 3. Measures of observer variability [kappa statistic]. CMAJ. 2004;171:1369–1379.)

Interpreting Kappa Values

Value of Kappa Strength of Agreement

<0.20 Poor
0.21–0.40 Fair

0.41–0.60 Moderate

0.61–0.80 Good

0.81–1.00 Excellent

HEALTH PROMOTION

C H A P T E R 2 |

Evaluating Clinical Evidence 55

Health Promotion
Throughout the book you will find health promotion sections that make recom-
mendations for primary prevention (interventions designed to prevent disease)
as well as secondary prevention (screening tests designed to find disease or dis-
ease processes at an early, asymptomatic stage). The rationale for secondary
prevention is that treatment for early-stage disease is often more effective than
treatment for later-stage disease. These health promotion recommendations are
based on guidelines issued by professional organizations. We highlight guide-
lines that are evidence-based, such as those produced by the U.S. Preventive
Services Task Force (USPSTF).13 Such guidelines consider the quality of the
evidence and the strength of the recommendation to either provide or withhold
the intervention.14 The strongest health promotion recommendations are based
on results from randomized controlled trials (or syntheses of multiple such tri-
als) of therapy or prevention.

The randomized controlled trial design reduces bias, thereby increasing the
validity of the results. Observational studies are more likely to have biased
results, and expert opinions may be offered in the absence of evidence. When
searching for evidence-based information, you should select the highest level of
available evidence (e.g., systematic reviews of high-quality randomized con-
trolled studies) (Fig. 2-5).15

ischemic heart disease or sending a patient home with an ischemic event. A
statistical test used to characterize precision is the coefficient of variation, defined
as the standard deviation divided by the mean value. Lower values indicate
greater precision.

Systematic
Reviews

Randomized Control Trials

Cohort Studies

Case-Control Studies

Case Series, Case Reports

Editorials, Expert Opinion

F I G U R E 2 – 5 . Evidence pyramid. (Adapted with permission from Sackett DL, Straus SE, Richardson WS,
et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh: Churchill Livingstone; 2000.)

CRITICAL APPRAISAL

56 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

During your health care training, it is essential that you learn the process of
critically appraising the clinical literature in order to be able to interpret new stud-
ies and guidelines as they appear throughout your professional career.

A widely accepted process for critically appraising the clinical literature has been
developed by The Evidence Based Working Group.16 These experts in epidemi-
ology, or the study of disease in populations, created a rigorous and standardized
approach for evaluating studies. This approach has been applied to a wide range
of clinical topics, including therapeutic and prevention trials, diagnostic tests,
meta-analysis, cost-effectiveness analyses, and practice guidelines. This approach
asks three basic questions:

1. Are the results valid (can you believe them)?

2. What are the results (magnitude and precision)?

3. How can you apply the results to patient care?

Understanding Bias

When evaluating study results, it is important to have a thorough understanding
of bias, which is a systematic error in conducting a study that threatens the valid-
ity of the results. Studies with a low risk of bias provide the most valid evidence
for clinical decision making and health promotion interventions. The key sources
of bias in clinical research are selection bias, performance bias, detection bias,
and attrition bias.17

Critical Appraisal

Types of Biases Affecting Evidence

Selection Bias
● Occurs when comparison groups have systematic differences in their baseline

characteristics that can affect the outcome of the study
● Creates problems in interpreting observed differences in outcomes because

they could result from the interventions or the baseline differences between

groups
● Randomly allocating subjects to the intervention is the best approach to mini-

mizing this bias

Performance Bias
● Occurs when there are systematic differences in the care received between

comparison groups (other than the intervention)
● Creates problems in interpreting outcome differences
● Blinding subjects and providers to the intervention is the best approach to

minimizing this bias

(continued )

CRITICAL APPRAISAL

C H A P T E R 2 |

Evaluating Clinical Evidence 57

Detection Bias
● Occurs when there are systematic differences in efforts to diagnose or ascer-

tain an outcome
● Blinding outcomes assessors (ensuring that they are unaware of the interven-

tion received by the subject) is the best approach to minimizing this bias

Attrition Bias
● Occurs when there are systematic differences in the comparison groups in the

number of subjects who do not complete the study
● Failing to account for these differences can lead to incorrectly estimating the

effectiveness of an intervention
● Using an intention-to-treat analysis, where all analyses consider all subjects

who were assigned to a comparison group, regardless of whether they received

or completed the intervention, can minimize this bias

Results

Assessing Performance of a Treatment or Prevention Intervention.
Other issues to consider in evaluating the quality of the literature include results
and generalizability. We have discussed the results found in studies of diagnostic
tests. Guidelines for health promotion are usually based on clinical trials of ther-
apy or prevention. Results from these studies are also calculated from a 2 × 2
table where the columns correspond to whether the subject developed the out-
come and the rows correspond to whether the subject received (or was exposed
to) the intervention. The statistics used to characterize the performance of a
treatment or prevention intervention include relative risks, relative risk differ-
ences (can be a reduction or increase, reflecting benefit or harm), absolute risk
differences (can be a reduction or increase, reflecting benefit or harm), numbers
needed to treat, and numbers needed to harm.18

2 ¥ 2 Tables for Evaluating Studies
of Treatment or Prevention

Event Occurred No Event Total

Experimental group a b a + b
Control group c d c + d

Calculating these statistics from the 2 × 2 table begins with determining proba-
bilities for outcomes.

â–  The probability that an intervention subject had the outcome is described by
a/(a + b) from row 1 (experimental group); this also called the experimental
event rate (EER).

Types of Biases Affecting Evidence (continued )

CRITICAL APPRAISAL

58 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

â–  The probability that a control subject had the outcome is c/(c + d) from row
2 (control group), or the control event rate (CER).

â–  The relative risk, the probability of an outcome in the intervention group
compared to the probability of an outcome in the control group, is expressed
as the EER/CER.

■ The relative risk difference is defined as |CER − EER|/CER × 100% or 100% −
the relative risk, which describes the proportion of baseline risk is reduced/
increased by the therapy.

â–  The absolute risk difference, the difference in outcome rates between the com-
parisons groups, is expressed by the |CER − EER|.

â–  The reciprocal of the absolute risk difference (reported as a fraction) is the
number of subjects who need to be treated over a specific period of time to pre-
vent one outcome. If the intervention actually increases the risk for a bad
outcome, then this statistic becomes the number needed to harm.

Measuring Treatment Effectiveness. An example of these calculations
is based on the hypothetical results of a study comparing the effects of a new
drug, CardioProtect (CP) versus a widely used drug, CareStandard (CS)
shown below. This 1-year randomized controlled trial compared patients who
survived a recent myocardial infarction to see whether the new drug would
reduce the outcome of a cardiovascular event, defined as fatal or non-fatal
myocardial infarction or cerebrovascular event. The drugs were coated so that
patients and providers could not tell them apart. Subjects receiving the CP are
the experimental group, and the EER = 10 events among 100 subjects = 0.10.
The control group received CS and the CER was 30 events among 100 sub-
jects = 0.30. The relative risk of having a cardiovascular event among the CP
group compared to the CS group is 0.10/0.30 = 0.33, or 33%. The relative risk
reduction is 1 – 0.33 = 0.67, or 67%, meaning that the risk of a cardiovascu-
lar event among the CP group is 67% lower than in the CS group. CP led to a
reduction in cardiovascular events, so we use the absolute risk reduction,
which is reported as a decimal: 0.3 − 0.1 = 0.2. The reciprocal of this value
(1/0.2) gives us a number needed to treat of 5—meaning that for every 5
patients who receive CP instead of CS there will be one fewer event. The num-
ber needed to treat is always based on a specific period of time, so that we
should say that we need to treat 5 patients for 1 year with CP compared to CS
to prevent one cardiovascular event.

Example of 2 ¥ 2 Tables for Evaluating Studies
of Treatment or Prevention

Cardiovascular Event No Event Total

CardioProtect 10 90 100

CareStandard 30 70 100

CRITICAL APPRAISAL

C H A P T E R 2 |

Evaluating Clinical Evidence 59

Generalizability

The final point to consider when evaluating the quality of the literature is
whether the results are generalizable (e.g., whether the study results can be
applied to your patients). To make this determination, you need to first look at
the demographics of the study subjects (e.g., age, gender, race/ethnicity, socioeco-
nomic status, clinical conditions). Then, you need to determine whether the
demographics are similar enough to your patient to make the results applicable.
You also need to determine whether the intervention is feasible in your setting.
Do you have the clinical expertise, technology, and capacity to offer the intervention?
Most importantly, you need to consider the range of potential benefits and harm
associated with the intervention and decide whether the intervention is accept-
able for your patient.

Guideline Recommendations

There are many approaches for rating the strength of recommendations and we
will discuss several grading systems.

United States Preventive Services Task Force (USPSTF) Approach. The
USPSTF assigns 1 of 5 ratings to its recommendations (Table 2-1). It also assigns
a level of certainty regarding net benefit (Table 2-2).

Grading of Recommendations, Assessment, Development, and
Evaluation (GRADE). The GRADE process rates the quality of the evidence
and grades the strength of recommendations in clinical guidelines.19 Developed
by an international group of guideline writers and evidence experts, the primary
goals of GRADE are to (1) clearly separate the quality of the evidence and the
strength of the recommendations and (2) provide clear, pragmatic interpreta-
tions of strong versus weak recommendations.

High-quality evidence that the benefit of an intervention outweighs the harm
warrants a strong recommendation and suggests that further research is unlikely
to change confidence in the estimated effect. Meanwhile, uncertainty about the
trade-offs between benefits and harm (e.g., due to low-quality evidence or closely
balanced risks and benefits) warrants a weak recommendation.

The American College of Chest Physicians (AACP) also developed a grading sys-
tem used by many organizations.20 The system classifies the quality of evidence
as high (grade A), moderate (grade B), or low (grade C) based on study design,
consistency of the results, and directness of the evidence. The system classifies the
strength of the recommendation as strong (grade 1) or weak (grade 2) based on
the estimated balance between benefits, risks, burdens, cost, and the degree of
confidence in the estimates. Table 2-3 provides more detail on the criteria and
definitions.

The health promotion sections will indicate the level of evidence behind the
various recommendations.

LOOKING AHEAD

60 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

Looking Ahead
This chapter introduces the concept of evidence-based clinical practice, showing
how to bring clinical evidence to patient care. Physical examination maneuvers
and elements of the clinical history can be seen as diagnostic tests and we have
shown how to evaluate their diagnostic performance. Information on diagnostic
performance will be further provided throughout the book. We also discussed
the evidence behind clinical guidelines and how a good guideline should char-
acterize that evidence and indicate the strength of recommendations to imple-
ment an intervention. We will provide this information when describing
guidelines in the Health Promotion and Counseling sections of each of the
regional examination chapters.

C H A P T E R 2 |

Evaluating Clinical Evidence 61

Table 2-1

Grade Definition Suggestions for Practice

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

Offer or provide this service.

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

Offer or provide this service.

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

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

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

Discourage the use of this service.

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

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

The USPSTF defines certainty as the “likelihood that the USPSTF assessment of the net benefit of a preventive service is correct.” The net benefit is defined as
benefit minus harm of the preventive service as implemented in a general, primary care population.

Source: Grade Definitions. U.S. Preventive Services Task Force. October 2014. http://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions.

U.S. Preventive Service Task Force Ratings:
Grade Definitions and Implications for Practice

62 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

Table 2-2 U.S. Preventive Services Task Force Levels
of Certainty Regarding Benefit

Level of Certainty Description

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

Moderate The available evidence is sufficient to determine the effects of the preventive service on health
outcomes, but confidence in the estimate is constrained by such factors as:
â–  The number, size, or quality of individual studies.
â–  Inconsistency of findings across individual studies.
â–  Limited generalizability of findings to routine primary care practice.
â–  Lack of coherence in the chain of evidence.

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

Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient
because of:
â–  The limited number or size of studies.
â–  Important flaws in study design or methods.
â–  Inconsistency of findings across individual studies.
â–  Gaps in the chain of evidence.
â–  Findings not generalizable to routine primary care practice.
â–  Lack of information on important health outcomes.

More information may allow estimation of effects on health outcomes.

Source: Update on Methods: Estimating Certainty and Magnitude of Net Benefit. U.S. Preventive Services Task Force. February 2014.
http://www.uspreventiveservicestaskforce.org/Page/Name/update-on-methods-estimating-certainty-and-magnitude-of-net-benefit.

C H A P T E R 2 |

Evaluating Clinical Evidence 63

Table 2-3 American College of Chest Physicians:
Grading Recommendations

Grade of
Recommendation/
Description

Benefit vs. Risk
and Burdens

Methodological Quality
of Supporting Evidence Implications

1A/Strong recommendation;
high-quality evidence

Benefits clearly outweigh
risk and burdens, or vice
versa

RCTs without important
limitations or overwhelming
evidence from observational
studies

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

1B/Strong recommendation;
moderate-quality evidence

Benefits clearly outweigh
risk and burdens, or vice
versa

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

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

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

Benefits clearly outweigh
risk and burdens, or vice
versa

Observational studies or case
series

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

2A/Weak recommendation;
high-quality evidence

Benefits closely balanced
with risk and burdens

RCTs without important
limitations or overwhelming
evidence from observational
studies

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

2B/Weak recommendation;
moderate-quality evidence

Benefits closely balanced
with risk and burdens

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

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

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

Uncertainty in the
estimates of benefits,
risks, and burden;
benefits, risks, and
burdens may be closely
balanced

Observational studies or case
series

Very weak recommendation;
other alternatives may be
equally reasonable

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

64 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

REFERENCES

References
1. Haynes RB, Sackett DL, Gray JM, et al. Transferring evidence from

research into practice: 1. The role of clinical care research evidence
in clinical decisions. ACP J Club. 1996;125(3):A14.

2. Richardson WS, Wilson M, Guyatt G. The process of diagnosis. In:
Guyatt G, Rennie D, eds. Users’ Guides to the Medical Literature. 2nd
ed. Chicago, IL: American Medical Association; 2008.

3. Jaeschke R, Guyatt G, Lijmer J. Diagnostic tests. In: Guyatt G,
Rennie D, eds. Users’ Guides to the Medical Literature. 2nd ed.
Chicago, IL: American Medical Association; 2008.

4. Sackett DL, Haynes RB, Guyatt GH, et al. Clinical Epidemiology. A
Basic Science for Clinical Medicine. 2nd ed. Boston, MA: Little,
Brown and Company; 1991.

5. Wolf AM, Wender RC, Etzioni RB, et al; American Cancer Society
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6. Thompson IM, Pauler DK, Goodman PJ, et al. Prevalence of pros-
tate cancer among men with a prostate-specific antigen level < or
= 4.0 ng per milliliter. N Engl J Med. 2004;350(22):2239.

7. Richardson WS, Wilson MC, Keitz SA, et al. Tips for teachers of
evidence-based medicine: making sense of diagnostic test results
using likelihood ratios. J Gen Intern Med. 2008;23(1):87.

8. Jaeschke R, Guyatt GH, Sackett DL. Users’ Guides to the Medical
Literature. III. How to use an article about a diagnostic test. B. What
are the results and will they help me in caring for my patients? The
Evidence-Based Medicine Working Group. JAMA. 1994;271(9):703.

9. Fagan TJ. Nomogram for Bayes theorem. N Engl J Med. 1975;
293:257.

10. Gigerenzer G. What are natural frequencies? BMJ. 2011;343:d6386.
11. Gigerenzer G, Gaissmaier W, Kurz-Milcke E, et al. Helping doctors

and patients make sense of health statistics. Psychol Sci Public Interest.
2008;8(2):53.

12. McGinn T, Guyatt G, Cook R, et al. Diagnosis. Measuring agreement
beyond chance. In: Guyatt G, Rennie D, eds. AMA’s Users’ Guides to
the Medical Literature: A Manual for Evidence-Based Clinical Practice.
2nd ed. Chicago, IL: American Medical Association; 2008.

13. Home. U.S. Preventive Services Task Force. January 2016. http://
www.uspreventiveservicestaskforce.org/Page/Name/home.

14. Grade Definitions. U.S. Preventive Services Task Force. October
2014. http://www.uspreventiveservicestaskforce.org/Page/Name/
grade-definitions.

15. Guyatt GH, Sackett DL, Sinclair JC, et al. Users’ Guides to the
Medical Literature. IX. A method for grading health care recom-
mendations. Evidence-Based Medicine Working Group. JAMA.
1995;274(22):1800.

16. Guyatt G, Rennie D, Meade M, et al. Users’ Guides to the Medical
Literature. 2nd ed. New York, NY: McGraw-Hill Company; 2008.

17. Jüni P, Altman DG, Egger M. Systematic reviews in health care:
Assessing the quality of controlled clinical trials. BMJ 2001;323:42.

18. Jaeschke R, Guyatt G, Barratt A, et al. Therapy and Understanding
the Results. Users’ Guides to the Medical Literature. 2nd ed. Chicago,
IL: American Medical Association; 2008.

19. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Intro-
duction-GRADE evidence profiles and summary of findings tables.
J Clin Epidemiol. 2011;64(4):383.

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

C H A P T E R 3 |

Interviewing and the Health History 65

The health history interview is a conversation with a purpose. As you learn to
elicit the patient’s story, you will draw on many of the interpersonal skills that you
use every day, but with unique and important differences. In social conversation,
you freely express your own views and are responsible only for yourself. In con-
trast, the primary goals of the patient interview are to listen and to improve the
well-being of the patient through a trusting and supportive relationship (Fig. 3-1).

Relating effectively with patients is among the most valued skills of clinical care.
For the patient, “a feeling of connectedness . . . of being deeply heard and under-
stood . . . is the very heart of healing.”1 For the clinician, this deeper relationship
enriches the rewards of patient care.2–4 High-quality patient–clinician commu-
nication has also been shown to improve patient outcomes, decrease symptoms,
improve functional status, reduce litigation, and decrease errors.5–7 The inter-
view is also the most commonly performed clinical intervention, occurring thou-
sands of times in a clinician’s career. These are all salient and compelling reasons
to develop expertise in this skill (Fig. 3-2).

This chapter introduces you to the essentials of interviewing and establishing
trust, the foundations of your therapeutic alliance with patients. At first, you will
focus on gathering information, but with experience and empathic listening, you
will allow the patient’s story to unfold in its most authentic and detailed form.

Interviewing is both a skill and an art. Skilled interviewing is both patient-centered
and clinician-centered. The clinician must focus on the patient to elicit the full story
of the patient’s symptoms, but the clinician must also interpret key information
to reach an assessment and plan. Patient-centered interviews “recognize the
importance of patients’ expressions of personal concerns, feelings, and emotions”
and evoke “the personal context of the patient’s symptoms and disease.”8 Experts
have defined patient-centered interviewing as “following the patient’s lead to
understand their thoughts, ideas, concerns and requests, without adding

C H A P T E R

3
Interviewing and the
Health History

The Bates’ suite offers these additional resources to enhance learning and facilitate
understanding of this chapter:
■ Bates’ Pocket Guide to Physical Examination and History Taking, 8th edition
■ Bates’ Visual Guide to Physical Examination (All Volumes)
â–  thePoint online resources, for students and instructors: http://thepoint.lww.com

F I G U R E 3 – 1 . History-taking

involves empathic listening.

F I G U R E 3 – 2 . Establish connections

with patients.

66 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

INTERVIEWING AND THE HEALTH HISTORY

additional information from the clinician’s perspective.” In contrast, in the more
symptom-focused, clinician-centered approach, the clinician “takes charge of the
interaction to meet her or his own need to acquire the symptoms, their details,
and other data that will help her or him identify a disease,” which can bypass the
personal dimensions of the illness.8,9 Evidence suggests that the patient is best
served by integrating these interviewing styles, leading to a more complete picture
of the patient’s illness and allowing clinicians to more fully convey the caring
attributes of “respect, empathy, humility and sensitivity.”8,10 Current evidence
shows that this approach is not only more satisfying for the patient and the clini-
cian, but also more effective in achieving desired health outcomes (Fig. 3-3).11,12

The interviewing process is quite different from the format of the health history,
presented in Chapter 1. The interview is more than just a series of questions; it
requires a highly refined sensitivity to the patient’s feelings and behavioral cues.
The health history format provides an important framework for organizing the
patient’s story into various categories pertinent to the patient’s present, past, and
family health. The interview and the health history format have distinct but
complementary purposes. Keep these differences in mind as you learn the
techniques of skilled interviewing.

The interviewing process that generates the patient’s story is fluid and draws on
numerous relational skills to respond effectively to patient cues, feelings, and
concerns. The adaptability of the interviewer has been compared to the impro-
visation of jazz musicians who listen attentively to notes and themes and play to
each other’s cues. This “in-the-moment” flexibility lets the interviewer adapt to
the patient’s leads as the story unfolds.13 The interview should be “open-ended,”
drawing on a range of techniques to cue patients to tell their stories—active
listening, guided questioning, nonverbal affirmation, empathic responses, vali-
dation, reassurance, and partnering. These techniques are especially valuable
when eliciting the patient’s chief concerns and the History of the Present Illness.

The health history format is a structured framework for organizing patient informa-
tion in written or verbal form. This format focuses your attention on the specific
kinds of information you need to obtain, facilitates clinical reasoning, and standard-
izes communication to other health care providers involved in the patient’s care. The
Past Medical History, the Family History, Personal and Social History, and Review of
Systems give shape and depth to the patient’s story. The Personal and Social History
is an opportunity for the clinician to see the patient as a person and gain deeper
understanding of the patient’s outlook and background. Learning about the patient’s
life circumstances, emotional health, perception of health care, health behaviors,
and access to and utilization of health care strengthens your therapeutic alliance and
improves health outcomes.14 Make every effort to limit the “clinician-centered,”
closed-ended “yes-no” questions to the Review of Systems.

Above all, skilled interviewing requires your lifelong commitment to masterful
listening, easily sacrificed to the time pressures of daily health care. In the words of
Sir William Osler, one of our greatest clinicians and co-founder of Johns Hopkins
School of Medicine in 1893: “Listen to your patient. He is telling you the diag-
nosis” and “The good physician treats the disease; the great physician treats the
patient who has the disease.”

F I G U R E 3 – 3 . Interviewing is

symptom- and patient-focused.

C H A P T E R 3 |

Interviewing and the Health History 67

DIFFERENT KINDS OF HEALTH HISTORIES

Different Kinds of Health
Histories

As you learned in Chapter 1, the scope and detail of the history depends on the
patient’s needs and concerns, your goals for the encounter, and the clinical setting
(inpatient or outpatient, the amount of time available, primary care or subspecialty).

â–  For new patients, in most settings, you will do a comprehensive health history.

â–  For patients seeking care for specific concerns, for example, cough or painful
urination, a more limited interview tailored to that specific problem may be
indicated; this is sometimes known as a focused or problem-oriented history.

â–  For patients seeking care for ongoing or chronic problems, focusing on the
patient’s self-management, response to treatment, functional capacity, and
quality of life is most appropriate.15

â–  Patients frequently schedule health maintenance visits with the more fo-
cused goals of keeping up screening examinations or discussing concerns
about smoking, weight loss, or sexual behavior.

â–  A specialist may need a more comprehensive history to evaluate a problem
with numerous possible causes.

By knowing the content and relevance of the different components of the com-
prehensive health history, you are able to select the elements most pertinent to
the visit and shared goals for the patient’s health. This chapter sets guideposts
for interviewing and the health history, outlined below.

See Chapter 1, Overview: Physical

Examination and History Taking,

pp. 3–43.

Chapter Overview

The Fundamentals of Skilled Interviewing
● The Techniques of Skilled Interviewing: Active listening. Empathic responses.

Guided questioning. Nonverbal communication. Validation. Reassurance.

Partnering. Summarization. Transitions. Empowering the patient.

The Sequence and Context of the Interview
● Preparation: Reviewing the clinical record. Setting goals for the interview.

Reviewing your clinical behavior and appearance. Adjusting the environment.
● The Sequence of the Interview: Greeting the patient and establishing rapport.

Taking notes. Establishing the agenda for the interview. Inviting the patient’s

story. Identifying and responding to emotional cues. Expanding and clarifying the

patient’s story. Generating and testing diagnostic hypotheses. Sharing the treat-

ment plan. Closing the interview and the visit. Taking time for self-reflection.
● The Cultural Context of the Interview: Demonstrating cultural humility—a

changing paradigm.

(continued )

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You may have many reasons for choosing to enter the health care professions,
but building effective and healing relationships is undoubtedly paramount.
“Those who suffer empower healers to witness, explain, and relieve their suffer-
ing.”2 This section describes the fundamental techniques of therapeutic inter-
viewing, the timeless skills you will continually polish as you care for patients.
These skills require practice and feedback from your teachers so that you can
monitor your progress. Over time, you will learn to select the techniques best
suited to the ever-changing dynamics of human behavior in your patient rela-
tionships. Key among these techniques are active listening and empathy, the
golden links to a therapeutic alliance.

Chapter Overview (continued )

Advanced Interviewing
● Challenging Patients: The silent patient. The confusing patient. The patient

with impaired capacity. The talkative patient. The angry or disruptive patient.

The patient with a language barrier. The patient with low literacy or low health

literacy. The hearing impaired patient. The blind patient. The patient with lim-

ited intelligence. The patient seeking personal advice. The seductive patient.
● Sensitive Topics: The sexual history. The mental health history. Alcohol and

prescribed and illicit drug use. Intimate partner and family violence. Death

and dying.

Ethics and Professionalism

The Fundamentals of
Skilled Interviewing

Skilled Interviewing Techniques

● Active listening
● Empathic responses
● Guided questioning
● Nonverbal communication
● Validation

● Reassurance
● Partnering
● Summarization
● Transitions
● Empowering the patient

Active Listening. Active listening lies at the heart of the patient interview.
Active listening means closely attending to what the patient is communicating,
connecting to the patient’s emotional state, and using verbal and nonverbal skills
to encourage the patient to expand on his or her feelings and concerns. Active
listening allows you to relate to those concerns at multiple levels of the patient’s
experience.16 This takes practice. It is easy to drift into thinking about your next
question or possible diagnoses and lose your concentration on the patient’s story.
Focus on what the patient is telling you, both verbally and nonverbally. Sometimes
your body language tells a different story from your words.

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Empathic Responses. Empathic responses are vital to patient rapport and
healing.17,18 Empathy has been described as the capacity to identify with the patient
and feel the patient’s pain as your own, then respond in a supportive manner.19
Empathy “requires a willingness to suffer some of the patient’s pain in the sharing
of suffering that is vital to healing.”20 As patients talk with you, they may convey, in
their words or facial expressions, feelings they have not consciously acknowledged.
These feelings are crucial to understanding their illnesses. To express empathy, you
must first recognize the patient’s feelings, then actively move toward and elicit
emotional content.21,22 At first, exploring these feelings may make you feel
uncomfortable, but your empathic responses will deepen mutual trust.

When you sense unexpressed feelings from the patient’s face, voice, behavior or
words, gently ask: “How do you feel about that?” or “That seems to trouble you,
can you say more?” Sometimes a patient’s response may not correspond to your
initial assumptions. Responding to a patient that the death of a parent must be
upsetting, when in fact the death relieved the patient of a heavy emotional bur-
den, reflects your interpretation, not what the patient feels. Instead, you can ask:
“You have lost your father. What has that been like for you?” It is better to ask
the patient to expand or clarify a point than assume you understand. Empathy
may also be nonverbal—placing your hand on the patient’s arm or offering tis-
sues when the patient is crying. Unless you affirm your concern, important
dimensions of the patient’s experience may go untapped.

Once the patient has shared these feelings, reply with understanding and accep-
tance. Your responses may be as simple as: “I cannot imagine how hard this must
be for you” or “That sounds upsetting” or “You must be feeling sad.” For a
response to be empathic, it must convey that you feel what the patient is feeling.

Guided Questioning: Options for Expanding and Clarifying the
Patient’s Story. There are several ways to elicit more information without
changing the flow of the patient’s story. Your goal is to facilitate full communication,
in the patient’s own words, without interruption. Guided questions show your
sustained interest in the patient’s feelings and deepest disclosures (Fig. 3-4).
They help you avoid questions that prestructure or even shut down the patient’s
responses. A series of “yes-no” questions makes the patient feel more restricted
and passive, leading to significant loss of detail. Instead, use guided questioning
to absorb the patient’s full story.

F I G U R E 3 – 4 . Employ guided

questioning.

For further practice see Smith,

Patient-Centered Interviewing.8Techniques of Guided Questioning

● Moving from open-ended to focused questions
● Using questioning that elicits a graded response
● Asking a series of questions, one at a time
● Offering multiple choices for answers
● Clarifying what the patient means
● Encouraging with continuers
● Using echoing

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Moving from Open-Ended to Focused Questions. Your questions
should flow from general to specific. Think about a cone, open at the top, then
tapering to a focal point. Start with the most general questions like, “How can I
help?” or “What brings you in today?” Then move to still open, but more focused,
questions like, “Can you tell me more about what happened when you took the
medicine?” Then pose closed questions like, “Did the new medicine cause any
problems?”

Begin with a truly open-ended question that does not prefigure an answer. A
possible sequence might be:

“Tell me about your chest discomfort.” (Pause)
“What else?” (Pause)
“Where did you feel it?” (Pause) “Show me.”
“Anywhere else?” (Pause) “Did it travel anywhere?” (Pause) “To which

arm?”

Avoid leading questions that already contain an answer or suggested response like:
“Has your pain been improving?” or “You don’t have any blood in your stools, do
you?” If you ask “Is your pain like a pressure?” and the patient answers yes,
the patient’s response is truncated instead of what he or she experienced. Adopt
the more neutral “Please describe your pain.”

Questioning That Elicits a Graded Response. Ask questions that
require a graded response rather than a yes-no answer. “How many steps can you
climb before you get short of breath?” is better than “Do you get short of breath
climbing stairs?”

Asking a Series of Questions, One at a Time. Be sure to ask one question
at a time. “Any tuberculosis, pleurisy, asthma, bronchitis, pneumonia?” may prompt
“No” out of sheer confusion. Try “Do you have any of the following problems?” Be
sure to pause and establish eye contact as you list each problem.

Offering Multiple Choices for Answers. Sometimes, patients need
help describing their symptoms. To minimize bias, offer multiple-choice answers:
“Which of the following words best describes your pain: aching, sharp, press-
ing, burning, shooting, or something else?” Almost any specific question can
contrast two possible answers. “Do you bring up any phlegm with your cough,
or is it dry?”

Clarifying What the Patient Means. Sometimes the patient’s history is
difficult to understand. It is better to acknowledge confusion than to act like the
story makes sense. To understand what the patient means, you need to request
clarification, as in “Tell me exactly what you mean by ‘the flu’” or “You said you
were behaving just like your mother. What did you mean?” Taking time for
clarification reassures the patient that you want to understand his or her story
and builds your therapeutic relationship.

Encouraging with Continuers. Without even speaking, you can use
posture, gestures, or words to encourage the patient to say more. Pausing and

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nodding your head, or remaining silent, yet attentive and relaxed, is a cue for
the patient to continue. Leaning forward, making eye contact, and using phrases
like “Mm-hmm,” or “Go on,” or “I’m listening” all enhance the flow of the
patient’s story.

Echoing. Simply repeating the patient’s last words, or echoing, encourages
the patient to elaborate on details and feelings. Echoing also demonstrates care-
ful listening and a subtle connection with the patient by using the same words.
For example:

Patient: “The pain got worse and began to spread.” (Pause)
Response: “Spread?” (Pause)
Patient: “Yes, it went to my shoulder and down my left arm to the fingers. It

was so bad that I thought I was going to die.” (Pause)
Response: “Going to die?”
Patient: “Yes, it was just like the pain my father had when he had his heart

attack, and I was afraid the same thing was happening to me.”

This reflective technique helped to reveal not only the location and severity
of the pain but also its meaning to the patient. It did not bias the story or inter-
rupt the patient’s train of thought.

Nonverbal Communication. Both clinicians and patients continuously
display nonverbal communication that provides important clues to our
underlying feelings. Being sensitive to nonverbal cues allows you to “read the
patient” more effectively and send messages of your own. Pay close attention
to eye contact, facial expression, posture, head position and movement such
as shaking or nodding, interpersonal distance, and placement of the arms or
legs—crossed, neutral, or open. Be aware that some forms of nonverbal
communication are universal, but many are culturally bound.

Just as mirroring your posture shows the patient’s sense of connection, matching
your position to the patient’s can transmit increased rapport. You can also mirror
the patient’s paralanguage, or qualities of speech, such as pacing, tone, and volume.
Moving closer or making physical contact like placing your hand on the patient’s
shoulder conveys empathy and can help the patient gain control of upsetting
feelings. The first step to using this important technique is to notice nonverbal
behaviors and bring them to conscious level.

Validation. Another way to affirm the patient is to validate the legitimacy of
his or her emotional experience. A patient caught in a car accident, even if
uninjured, may still feel very distressed. Saying something like, “Your accident
must have been very scary. Car accidents are always unsettling because they
remind us how vulnerable we are. Perhaps that explains why you still feel upset,”
validates the patient’s response as legitimate and understandable.

Reassurance. When patients are anxious or upset, it is tempting to
provide reassurance like “Don’t worry. Everything is going to be all right.”
Although this is common in social interactions, for clinicians, such comments
may be premature and counterproductive. Depending on the actual situation,

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they may even be misleading and block further disclosure. The patient may
sense that you are uncomfortable handling anxiety or fail to appreciate the
depth of the distress.

The first step to effective reassurance is simply identifying and acknowledging the
patient’s feelings. For example, you might simply say, “You seem upset today.”
This promotes a feeling of connection. Meaningful reassurance comes later,
after you have completed the interview, the physical examination, and perhaps
some laboratory tests. At that point, you can explain what you think is hap-
pening and deal openly with any concerns. Reassurance is more appropriate
when the patient feels that problems have been fully understood and are being
addressed.

Partnering. When building rapport with patients, express your commitment
to an ongoing relationship. Make patients feel that no matter what happens, you
will continue to provide their care. Even as a student, especially in a hospital
setting, this support can make a big difference.

Summarization. Giving a capsule summary of the patient’s story during
the course of the interview serves several purposes. It communicates that you
have been listening carefully. It identifies what you know and what you don’t
know. “Now, let me make sure that I have the full story. You said you’ve had a
cough for 3 days, that it’s especially bad at night, and that you have started to
bring up yellow phlegm. You have not had a fever or felt short of breath, but
you do feel congested, with difficulty breathing through your nose.” Following
with an attentive pause, or asking “Anything else?” lets the patient add other
information and corrects any misunderstandings.

You can use summarization at different points in the interview to structure the
visit, especially at times of transition (see below). This technique also allows you
to organize your clinical reasoning and convey your thinking to the patient,
making the relationship more collaborative. It also helps learners when they
draw a blank on what to ask next.

Transitions. Patients may be apprehensive during a health care visit. To
put them more at ease, tell them when you are changing directions during the
interview. Just like signs along the highway, “signposting” transitions help
prepare patients for what comes next. As you move through the history and on
to the physical examination, orient the patient with brief transitional phrases
like “Now I’d like to ask some questions about your past health.” Make clear
what the patient should expect or do next. “Before we move on to reviewing
all your medications, was there anything else about past health problems?”
“Now I would like to examine you. I will step out for a few minutes. Please
undress and put on this gown.”

Empowering the Patient. The clinician–patient relationship is inherently
unequal. Your feelings of inexperience as a student predictably change over time
as you grow in clinical experience. Patients, however, have many reasons to feel
vulnerable. They may be in pain or worried about a symptom. They may feel
overwhelmed by even scheduling a visit, a task you might take for granted.

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Differences of gender, ethnicity, race, or socioeconomic status contribute to the
power asymmetry of the relationship. Ultimately, however, patients are
responsible for their own care.23 When you empower patients to ask questions,
express their concerns, and probe your recommendations, they are most likely
to adopt your advice, make lifestyle changes, or take medications as prescribed
(Fig. 3-5).21

Listed below are techniques for sharing power with your patients. Although
many have already been discussed, reinforcing patients’ responsibility for their
health is fundamental and worth summarizing here. F I G U R E 3 – 5 . Share power with

patients.

Empowering the Patient:
Techniques for Sharing Power

● Evoke the patient’s perspective.
● Convey interest in the person, not just the problem.
● Follow the patient’s leads.
● Elicit and validate emotional content.
● Share information with the patient, especially at transition points during the

visit.
● Make your clinical reasoning transparent to the patient.
● Reveal the limits of your knowledge.

The Sequence and Context
of the Interview

Preparation, Sequence, and Cultural Context

Preparation: Reviewing the clinical record. Setting goals for the interview.
Reviewing your clinical behavior and appearance. Adjusting the environment.

The Sequence of the Interview: Greeting the patient and establishing rapport.
Establishing the agenda for the interview. Inviting the patient’s story. Exploring

the patient’s perspective. Identifying and responding to emotional cues. Expand-

ing and clarifying the patient’s story. Generating and testing diagnostic hypothe-

ses. Sharing the treatment plan. Closing the interview and the visit. Taking time

for self-reflection.

The Cultural Context of the Interview: Demonstrating cultural humility—a
changing paradigm.

Now that you have learned the fundamentals of skilled interviewing, you are
ready to start the interview. First, prepare for the interview by reviewing the
record and setting goals for the interview ahead. Check your appearance.
Make sure the patient is comfortable and the environment is conducive to the

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very personal information soon to be shared. You will find that each interview
has its own rhythm and sequence. Master the steps described. Finally, the
interview has important societal dimensions. Reflect on any biases you have
that color your reactions to the patient and the therapeutic alliance you need
to create.

Preparation

Interviewing patients requires planning. As you begin, consider several steps that
are crucial to success.

Reviewing the Clinical Record. Before seeing the patient, review the
clinical record (Fig. 3-6). This provides important background information and
suggests areas you need to explore. Review identifying data such as age, gender,
address, and insurance. Look at the problem list and the patient’s medications
and allergies. Even though the clinical record usually contains past diagnoses
and treatments, you need to make your own assessment based on what you
learn from the visit ahead. The clinical record is compiled from many observers.
Data may be incomplete or even disagree with what the patient tells you.
Correcting discrepancies in the record is important for the patient’s care.

Setting Goals for the Interview. Before you talk with the patient,
clarify your goals for the interview. As a student, your primary purpose may be
to complete a comprehensive history required for your rotation. As a practicing
clinician, your goals can range from assessing a new concern, to treatment
follow-up, to completing forms. The clinician must balance these provider-centered
goals with patient-centered goals, weighing multiple agendas arising from the needs
of the patient, the patient’s family, and health care agencies and facilities. Taking
a few minutes to think about your goals makes it easier to align your priorities
with the patient’s agenda.24

Reviewing Your Clinical Behavior and Appearance. Just as you
carefully observe the patient, the patient will be watching you. Consciously or
not, you send messages through both your words and your behavior. Posture,
gestures, eye contact, and tone of voice all convey the extent of your interest,
attention, acceptance, and understanding. The skilled interviewer seems calm and
unhurried, even when time is limited. Patients sense when you are preoccupied. It
is important to learn to focus and give the patient your full attention. Patients are
also sensitive to any implied disapproval, embarrassment, impatience, or boredom
and to behaviors that condescend, stereotype, criticize, or belittle. Professionalism
requires equanimity and “unconditional positive regard” to nurture healing
relationships.25 Your appearance is also important. Patients find cleanliness,
neatness, conservative dress, and a name tag reassuring. Remember to keep the
patient’s perspective in mind if you want to build the patient’s trust.

Adjusting the Environment. Make the interview setting as private and
comfortable as possible. You may have to talk with the patient in surroundings
like a two-bed room or the corridor of a busy emergency department. Making
the environment as confidential as possible improves communication. If there

F I G U R E 3 – 6 . Review records and

set goals.

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are privacy curtains, try to pull them shut. Suggest moving to an empty room
instead of talking in a waiting area. Adjust the room temperature for the patient’s
comfort. As the clinician, it is part of your role to make the patient more comfortable.
These efforts are always worth the time.

The Sequence of the Interview

In general, an interview moves through several stages. Throughout this sequence,
as the clinician you must remain attuned to the patient’s feelings, help the patient
express them, respond to their content, and validate their significance. As a stu-
dent, you will concentrate primarily on eliciting the patient’s story and creating
a shared understanding of the patient’s concerns. Later on, as a practicing clini-
cian, reaching agreement on a plan for further evaluation and treatment becomes
more important. Whether the interview is comprehensive or focused, pay close
attention to the patient’s feelings and affect, always working on strengthening the
relationship as you move through the typical sequence that follows. Including
the patient’s feelings, ideas, and expectations leads to therapeutic interventions
best suited to the patient’s needs, coping skills, and life circumstances.

Greeting the Patient and Establishing Rapport. The initial
moments of your encounter lay the foundation for your ongoing relationship.
How you greet the patient and other visitors in the room, provide for the
patient’s comfort, and arrange the physical setting all shape the patient’s first
impressions.

As you begin, greet the patient by name and introduce yourself, giving your own name.
If possible, shake hands with the patient. If this is the first contact, explain your
role, your status as a student, and how you will be involved in the patient’s
care. Introduce yourself during future meetings until you are sure the patient
knows who you are: “Good morning, Mr. Peters. I am Susannah Velasquez, a third-
year clinical student. You may remember me. I was here yesterday talking with you
about your heart problems. I am part of the clinical team taking care of you.”

In general, use a formal title to address the patient, Mr. O’Neil or Ms. Washington
for example.25 Except with children or adolescents, avoid first names until you
have specific permission. Calling a patient “dear” or overly familiar names can
depersonalize and demean. If you are unsure how to pronounce the patient’s
name, don’t be afraid to ask. You can say, “I am afraid of mispronouncing your
name. Could you say it for me?” Then repeat it to make sure that you heard it
correctly.

When visitors are in the room, acknowledge and greet each one in turn, inquir-
ing about each person’s name and relationship to the patient. Whenever visitors
are present, you are obligated to maintain the patient’s confidentiality. Let the patient
decide if visitors or family members should stay in the room, and ask for the
patient’s permission before conducting the interview in front of them. For exam-
ple, “I am comfortable with having your sister stay for the interview, Mrs. Jones,
but I want to make sure that this is what you want” or “Is it better if I speak to
you alone or with your sister present?” For sensitive questions, you may need to
arrange another time to be with the patient alone.

See Chapter 18, Assessing Children,

Infancy Through Adolescence, for

discussion of visitors present during

pediatric visits, pp. 765–891.

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Always be attuned to the patient’s comfort. In the office or clinic, help the patient find
a place for coats and belongings. In the hospital, after greeting the patient, ask
how the patient is feeling and if you are coming at a convenient time. Arranging
the bed to make the patient more comfortable or waiting a few minutes while the
patient says goodbye to visitors or finishes in the bathroom shows that you are
attentive to the patient’s needs. In any setting, look for signs of discomfort, such
as shifting position or facial expressions of pain or anxiety. Attend to these signs
first to promote trust and provide enough comfort for the interview to proceed.

Consider the best way to arrange the room and how close you should be to the
patient. Remember that cultural background and individual taste influence
preferences about interpersonal space. Choose a distance that facilitates conver-
sation and allows good eye contact (Fig. 3-7). You should probably be within
several feet, close enough to hear and be heard clearly. Pull up a chair and, if
possible, sit at eye level with the patient. Move physical barriers like bed railings
or bedside tables out of the way. In an outpatient setting, sitting on a rolling
stool, for example, allows you to change distances in response to patient cues.
Avoid arrangements that convey disrespect, like interviewing a woman already
positioned for a pelvic examination or talking through a bathroom door. Light-
ing also makes a difference. If you sit between a patient and a bright light or
window the patient may have to squint to see you, lending the interaction an
air of interrogation.

As you begin the interview, give the patient your undivided attention. Spend
enough time on small talk to put the patient at ease, and avoid looking down to
take notes, read the chart, or scan a computer screen. Show interest in the patient
as a unique individual. You can begin by asking, “So that I can get to know you,
tell me about yourself.”26

Taking Notes. As a novice, you may need to write down much of what
you learn during the interview. Experienced clinicians usually recall much of the
interview without any notes, but few remember all the details of a comprehen-
sive history. Jot down short phrases, specific dates, or words; but do not let note
taking or the laptop screen distract you from the patient. Maintain good eye
contact. If the patient is talking about sensitive or disturbing material, put down
your pen or move away from the keyboard. For patients who find note taking
uncomfortable, explore their concerns and explain your need to make an accu-
rate record. When using an electronic health record, face the patient directly as
you elicit the patient’s story, maintaining good eye contact and observing non-
verbal behaviors; turn to the screen only after engaging the patient in the goals
for the visit. Look up at the patient as often as possible, readjusting your screen
and position if needed.27

Establishing the Agenda. Once you have established rapport, you are
ready to pursue the patient’s reason for seeking care, traditionally called the
chief complaint. In the ambulatory setting, where there are often three or four
reasons for the visit, the phrase presenting problem(s) may be preferable. One
benefit to this phrase is that it does not characterize the patient as a complainer.
Begin with open-ended questions that allow full freedom of response: “What
are your special concerns today?”, “How can I help you?”, or “Are there specific

F I G U R E 3 – 7 . Choose a distance

that facilitates conversation and eye

contact.

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concerns that prompted your appointment today?” These questions encourage
the patient to talk about any kinds of concerns, not just clinical ones. Note that
the first problem the patient mentions may not be the one that is most
important.28 Often, patients give one reason for the visit to the nurse and
another to you. For some visits, patients do not have a specific concern and
only “want a check-up.”

Identifying all the concerns at the outset allows you and the patient to decide
which ones are most pressing and which ones can be postponed to a later visit.
Questions such as “Is there anything else?”, “Have we got everything?”, or “Is
there anything we missed?” help you uncover the patient’s full agenda and “the
real reason” for the visit. You may want to address different goals, like discussing
an elevated blood pressure or an abnormal test result. Identifying the full agenda
protects time for the most important issues. However, even negotiating the
agenda at the outset does not avert “oh by the way” concerns that suddenly
emerge at the end of the visit.

Inviting the Patient’s Story. Once you have prioritized the agenda,
invite the patient’s story by asking about the foremost concern, “Tell me more
about…” Encourage patients to tell their stories in their own words, using an
open-ended approach. Avoid biasing the patient’s story—do not inject new
information or interrupt. Instead, use active listening skills: lean forward as you
listen; add continuers such as nodding your head and phrases like “uh huh,” “go
on,” or “I see.” Train yourself to follow the patient’s leads. If you ask specific
questions prematurely, you risk suppressing details in the patient’s own words.
Studies show that clinicians wait only 18 seconds before they interrupt.28 Once
interrupted, patients usually do not resume their stories. After the patient’s
initial description, explore the patient’s story in more depth. Ask, “How would you
describe the pain?”, “What happened next?”, or “What else did you notice?” so that the
patient enriches important details.

Exploring the Patient’s Perspective. The disease/illness distinction
model helps elucidate the different yet complementary perspectives of the clinician
and the patient.29 Disease is the explanation that the clinician uses to organize
symptoms that leads to a clinical diagnosis. Illness is a construct that explains how
the patient experiences the disease, including its effects on relationships, function,
and sense of well-being. Many factors may shape this experience, including prior
personal or family health, its impact on everyday life, the patient’s outlook, style of
coping, and expectations about care. The clinical interview needs to incorporate both
these views of reality. The melding of these two perspectives forms the basis for
planning evaluation and treatment.

Even a straightforward concern like sore throat can illustrate these divergent
views. The patient may be worried about pain and difficulty swallowing, missing
time from work, or a cousin who was hospitalized with tonsillitis. The clinician
may focus on specific points in the history that differentiate streptococcal phar-
yngitis from other etiologies, or on a questionable history of allergy to penicillin.
To understand the patient’s perspective, the clinician needs to explore the four
domains below. This information is crucial to patient satisfaction and patient
compliance.8,30

See pp. 70–71 for discussions

of continuers.

See pp. 69–71 for discussions

of guided questioning.

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Exploring the Patient’s Perspective (F-I-F-E)

● The patient’s Feelings, including fears or concerns, about the problem
● The patient’s Ideas about the nature and the cause of the problem
● The effect of the problem on the patient’s life and Function
● The patient’s Expectations of the disease, of the clinician, or of health care,

often based on prior personal or family experiences

To explore the patient’s perspective, use different types of questions. To uncover the
patient’s feelings, ask, “What concerns you most about the pain?” or “How
has this been for you?” For views about the cause of the problem, ask, “Why do you
think you have this [stomachache]?” You might ask, “What have you tried to help?”
since these choices suggest how the patient perceives the cause. Some patients
worry that their pain is a symptom of serious disease. Others just want relief. To
determine how the illness affects the patient’s lifestyle, particularly if the illness is
chronic, ask, “What did you do before that you can’t do now? How has your [back-
ache, shortness of breath, etc.] affected you? Your life at home? Your social activities?
Your role as a parent? Your function in intimate relationships? The way you feel
about yourself as a person?” To find out what the patient expects from you or from
the encounter in general, consider asking, “I am glad the pain is almost gone, how
specifically can I help you now?” Even if the pain is gone, the patient may still need
a work excuse to take to an employer. A mnemonic for the patient’s perspective on
the illness is FIFE—Feelings, Ideas, effect on Function, and Expectations.

Identifying and Responding to the Patient’s Emotional Cues.
Illness is often accompanied by emotional distress; 30% to 40% of patients have
anxiety and depression in primary care practices.31 Visits tend to be longer when
clinicians miss emotional clues. Patients may withhold their true concerns in up
to 75% of acute care visits even though they give clues to these concerns that are
direct, indirect, verbal, nonverbal, or disguised as related ideas or emotions.32
Check on these clues and feelings by asking, “How did you feel about that?” or
“Many people would be frustrated by something like this.” See the box below for
a taxonomy of the clues about the patient’s perspective on illness.

Clues to the Patient’s Perspective on Illness

● Direct statement(s) by the patient of explanations, emotions, expectations,

and effects of the illness
● Expression of feelings about the illness without naming the illness
● Attempts to explain or understand symptoms
● Speech clues (e.g., repetition, prolonged reflective pauses)
● Sharing a personal story
● Behavioral clues indicative of unidentified concerns, dissatisfaction, or unmet

needs such as reluctance to accept recommendations, seeking a second

opinion, or early return appointment

Source: Lang F, Floyd MR, Beine KL. Clues to patients’ explanations and concerns about their ill-

nesses: a call for active listening. Arch Fam Med. 2000;9:222.

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Learn to respond attentively to emotional cues using techniques like reflection,
feedback, and “continuers” that convey support. A mnemonic for responding to
emotional cues is NURSE: Name—“That sounds like a scary experience”; Under-
stand or legitimize—“It’s understandable that you feel that way”; Respect—
“You’ve done better than most people would with this”; Support—“I will
continue to work with you on this”; and Explore—“How else were you feeling
about it?”33,34

Expanding and Clarifying the Patient’s Story. As you elicit the
patient’s story, you must diligently clarify the attributes of each symptom,
including context, associations, and chronology. For pain and many other
symptoms, understanding these essential characteristics, summarized as the
seven attributes of a symptom, is critical.

To pursue the seven attributes, two mnemonics may help:

â–  OLD CARTS, or Onset, Location, Duration, Character, Aggravating/
Alleviating Factors, Radiation, and Timing, or

â–  OPQRST, or Onset, Palliating/Provoking Factors, Quality, Radiation, Site,
and Timing

The Seven Attributes of a Symptom

1. Location. Where is it? Does it radiate?
2. Quality. What is it like?
3. Quantity or severity. How bad is it? (For pain, ask for a rating on a scale of

1 to 10.)

4. Timing. When did (does) it start? How long does it last? How often does it
come?

5. Onset (setting in which symptom occurs). Include environmental factors,
personal activities, emotional reactions, or other circumstances that may

have contributed to the illness.

6. Remitting or exacerbating factors. Is there anything that makes it better or
worse?

7. Associated manifestations. Have you noticed anything else that
accompanies it?

Whenever possible, repeat back the patient’s words and expressions as the history
unfolds, to affirm the patient’s experience as you clarify what he or she means.
Although using clinical terminology is tempting, these terms can leave patients
confused and frustrated. Be aware of how easily jargon like “take a history”
and “work you up” can creep into your discussions. Choose plain language
for reflecting back the patient’s story, for example, “You said there was ‘a heavy
weight’ on your chest. Can you tell me more about that?” Or, to help clarify
the meaning of a patient symptom by offering a choice of responses, ask, “You
mentioned you were light-headed. Did you feel like fainting or that your legs
were just weak?” It is highly important to establish the sequence and time course

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of each of the patient’s symptoms to ensure that your assessments are based
on a fully accurate history. To establish the correct chronological order, ask
questions like “What then?” or “What happened next?” or “Please start at the
beginning, or the last time you felt well, and go step by step.” To fill in specific
details, vary the types of questions and interviewing techniques that you use,
including focused questions for information that is still missing. In general, an
interview moves back and forth from open-ended questions to increasingly focused
questions and then on to another open-ended question, returning the lead in the
interview to the patient.

Generating and Testing Diagnostic Hypotheses. As you gain
experience listening to patient concerns, you will deepen your skills of clinical
reasoning. You will generate and test diagnostic hypotheses about which disease
process might be present. Identifying all the features of each symptom is
fundamental to recognizing patterns of disease and to generating the differential
diagnosis. It is important to fully flesh out the patient’s story. This avoids the
common trap of premature closure, or shutting down the patient’s story too
quickly, which can lead to errors in diagnosis.35

It is helpful to visualize the process of evoking a full description of each symptom
as “the cone” (Fig. 3-8).

Each symptom has its own “cone,” which becomes a paragraph in the History of
Present Illness in the written record.

Questions about clusters of symptoms in common clinical entities are also
found in “The Health History” section of each of the regional physical exam-
ination chapters. The interview is your primary source of evidence for and
against various diagnostic possibilities. The challenge is to avoid a clinician-
centered agenda, letting focused questions take over that obscure the patient’s
perspective and limit your opportunity to create an empathic therapeutic
connection.

Sharing the Treatment Plan. Learning about the disease and
conceptualizing the illness allow you and the patient to create a shared picture

See Skilled Interviewing Techniques

and discussion of focused questions,

pp. 68–73.

First, open-ended questions to
hear “the story of the symptom”
in the patient’s own words

Then more specific questions to
elicit “the seven features of every
symptom”

Finally, the yes-no questions or
“pertinent positives and negatives”
from the relevant section of the
review of systems

F I G U R E 3 – 8 . Gather a full description of each symptom.

For example, in a patient with a

cough, the yes-no questions would

come from the Respiratory section of

the Review of Systems, on p. 12.

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See Table 3-1, Motivational Interview-

ing: A Clinical Example, p. 104.

of the patient’s problems. This multifaceted picture then forms the basis for
planning further evaluation (e.g., physical examination, laboratory tests,
consultations) and negotiating a treatment plan. Shared decision-making has
been called the pinnacle of patient-centered care.36 Experts recommend a
three-step process: introducing choices and describing options using patient
decision support tools when available; exploring patient preferences; and
moving to a decision, checking that the patient is ready to make a decision and
offering more time, if needed.37

Behavior Change and Motivational Interviewing. Many of your
patient visits will close with a discussion of behavior changes needed to opti-
mize health or treat illness. These could include a change in diet, exercise
habits, cessation of smoking or drinking, adherence to medication regimens,
or self-management strategies, among others.38 Advanced techniques such as
motivational interviewing and the therapeutic use of the clinician–patient
relationship are beyond the scope of this book. Nonetheless, it is worthwhile
to introduce the principles of motivational interviewing, a set of well-docu-
mented techniques that improve health outcomes, especially for patients with
substance abuse.39 Motivational interviewing helps patients “to say why and
how they might change, and is based on the use of a guiding style” of inter-
viewing, rather than direct advice. It engages patients to express the pros and
cons of a given behavior.40 Motivational interviewing makes the assumption
that many patients already know what is best for them and helps them con-
front their ambivalence to change.41 Using three core skills empowers the
patient to provide ideas, solutions, and a timetable for change, as shown in the
following table.

The Guiding Style of Motivational Interviewing

1. “Ask” open-ended questions—invite the patient to consider how and why
they might change.

2. “Listen” to understand your patient’s experience—“capture” their account
with brief summaries or reflective listening statements such as “quitting

smoking feels beyond you at the moment”; these express empathy, encourage

the patient to elaborate, and are often the best way to respond to resistance.

3. “Inform”—by asking permission to provide information, and then asking what
the implications might be for the patient.

Source: Quoted directly from Rollnick S, Butler CC, Kinnersly P, et al. Motivational Interviewing.

BMJ. 2010;340:1242.

See Table 3-2, Brief Action Planning

(BAP)—A Self-Management Support

Tool, p. 105.

Closing the Interview and the Visit. You may find that ending the
health history interview, and later concluding the visit, are difficult. Patients often
have many questions, and if you have done your job well, they feel engaged and
affirmed as they talk with you. Let the patient know that the end of the interview
or the visit is approaching to allow time for any final questions. Make sure the
patient understands the mutual plans you have developed. For example, before
gathering your papers or standing to leave the room, you can say, “We need to

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stop now. Do you have any questions about what we’ve covered?” As you close,
summarizing plans for future evaluation, treatments, and follow-up is helpful. A
useful technique to assess the patient’s understanding is to “teach back,”
whereby you invite the patient to tell you, in his or her own words, the plan of
care. An example would be: “Could you please tell me what you understand is
our plan of care?”42,43

The patient should have a chance to ask any final questions, but the last few
minutes are not a good time to bring up new topics. If this happens and the
concern is not life threatening, simply assure the patient of your interest and
make plans to address the problem at a future time. “That knee pain sounds
concerning. Why don’t you make an appointment for next week so we can dis-
cuss it?” Reaffirming your ongoing commitment to the patient’s health shows
your involvement and esteem.

Taking Time for Self-Reflection. The role of self-reflection, or
mindfulness, in developing clinical empathy cannot be overemphasized.
Mindfulness refers to the state of being “purposefully and nonjudgmentally
attentive to [one’s] own experience, thoughts, and feelings.”44 As you encounter
people of diverse ages, gender identities, social class, race, and ethnicity, being
consistently respectful and open to individual differences is an ongoing challenge
of clinical care. Because we bring our own values, assumptions, and biases to
every encounter, we must look inward to see how our own expectations and
reactions affect what we hear and how we behave. Self-reflection is a continual part
of professional development in clinical work. It brings a deepening personal awareness
to our work with patients. This personal awareness is one of the most rewarding aspects
of patient care.45

The Cultural Context of the Interview

Demonstrating Cultural Humility—A Changing Paradigm.
Communicating effectively with patients from every background has always
been an important professional skill. Nonetheless, the disparities in risks of
disease, morbidity, and mortality are marked and broadly documented across
different population groups, reflecting inequities in health care access, income
level, type of insurance, educational level, language proficiency, and provider
decision making.46,47 To moderate these disparities, clinicians are increasingly
urged to engage in self-reflection, critical thinking, and cultural humility as they
experience diversity in their clinical practices.48–50

Cultural competence is commonly viewed as “a set of attitudes, skills, behav-
iors, and policies that enable organizations and staff to work effectively in
cross-cultural situations. It reflects the ability to acquire and use knowledge
of the health-related beliefs, attitudes, practices, and communication pat-
terns of clients and their families to improve services, strengthen programs,
increase community participation, and close the gaps in health status among
diverse population groups.”51 Culturally competent care requires “under-
standing of and respect for the cultures, traditions, and practices of a com-
munity.”52 For example, Asians and Pacific Islanders for Reproductive
Health have cited environmental toxins as threats to food safety, and the

See Chapters 4 to 20, sections on

Health Promotion and Counseling:

Evidence and Recommendations and

selected notations in the Examples of

Abnormalities columns.

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Native American Women’s Health Education Resource Center has included
sovereignty and the right to parent as Native Americans in their agendas for
health.

Experts caution that too often, cultural competence is reduced to a static decon-
textualized set of traits and beliefs for particular ethnic groups that objectifies
patients as “other,” implicitly reinforcing the perspectives of the dominant, often
Western, culture.53 Instead, “culture is ever-changing and always being revised
within the dynamic context of its enactment.” However, “this dynamic is often
compromised by various sociocultural mismatches between patients and provid-
ers.”54 Such mismatches arise from clinicians’ lack of knowledge about patient
beliefs and lived experiences as well as unintentional or intentional enactment of
stereotypes and bias during patient encounters.

Instead, move toward the precepts of cultural humility. Cultural humility is
defined as a “process that requires humility as individuals continually engage in
self-reflection and self-critique as lifelong learners and reflective practitio-
ners.”54 It is a process that includes “the difficult work of examining cultural
beliefs and cultural systems of both patients and providers to locate the points
of cultural dissonance or synergy that contribute to patients’ health outcomes.”55
It calls for clinicians to “bring into check the power imbalances that exist in the
dynamics of (clinician)–patient communication” and maintain mutually
respectful and dynamic partnerships with patients and communities. To attain
these attributes, seek out the more effective training models that continue to
emerge.56–60

Begin your commitment to self-reflective practice by studying the vignettes
that follow. These examples illustrate how cultural differences and uncon-
scious bias can unwittingly lead to poor communication and poor patient
outcomes.

A 28-year-old taxi driver from Ghana who had recently moved to the United

States complained to a friend about U.S. clinical care. He had gone to the clinic

because of fever and fatigue. He described being weighed, having his tempera-

ture taken, and having a cloth wrapped tightly, to the point of pain, around his

arm. The clinician, a 36-year-old woman from Washington, D.C., asked the

patient many questions, examined him, and wanted to take blood, which the

patient had refused. The patient’s final comment was “ . . . and she didn’t even

give me chloroquine!”—his primary reason for seeking care. The man from

Ghana was expecting few questions, no examination, and treatment for malaria,

which is what fever usually means in Ghana.

Cultural Humility: Scenario 1

In this example, cross-cultural miscommunication is understandable and thus
less threatening to explore. Unconscious bias leading to miscommunication,
however, occurs in many clinical interactions. Consider the scenario below that
is closer to daily practice.

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Cultural Humility: Scenario 2

A 16-year-old high school student came to the local teen health center because

of painful menstrual cramps that interfered with her concentration at school.

She was dressed in a tight top and short skirt and had multiple piercings. The

30-year-old male clinician asked the following questions: “Are you passing all of

your classes? What kind of job do you want after high school? What kind of birth

control do you want?” The teen felt pressured into accepting birth control pills,

even though she had clearly stated that she had never had intercourse and

planned to postpone it until she got married. She was an honor student plan-

ning to go to college, but the clinician did not elicit these goals. The clinician

glossed over her cramps by saying, “Oh, you can just take some ibuprofen.

Cramps usually get better as you get older.” The patient will not take the birth

control pills that were prescribed, nor will she seek health care soon again. She

experienced the encounter as an interrogation, so failed to gain trust in her cli-

nician. In addition, the clinician’s questions made assumptions about her life and

did not show respect for her health concerns. Even though the provider pursued

important psychosocial domains, she received ineffective health care because of

conflicting cultural values and clinician bias.

In both of these cases, the failure stems from mistaken assumptions or biases.
In the first case, the clinician did not consider the many variables affecting
patient beliefs about health and expectations for care. In the second case, the
clinician allowed stereotypes to dictate the agenda instead of listening to the
patient and respecting her as an individual. Each of us has our own cultural
background and our own biases. These do not simply fade away as we become
clinicians.

As you provide care for an ever-expanding and diverse group of patients, you
must recognize how culture shapes not only the patient’s beliefs, but also
your own. Culture is the system of shared ideas, rules, and meanings that
influences how we view the world, experience it emotionally, and behave in
relation to other people. It can be understood as the “lens” through which we
perceive and make sense out of the world we inhabit. The meaning of culture
is much broader than the term “ethnicity.” Cultural systems are not limited
to minority groups; they emerge in many social groupings, including clinical
professionals.

Avoid letting personal impressions about cultural groups turn into professional
stereotyping. For example, you may have heard that Hispanic patients are more
dramatic when they express pain. Recognize that this is a stereotype. Evaluate
each patient as an individual, not decreasing the dose of analgesics, but staying
attuned to your reactions to the patient’s style. Work on an informed clinical
approach to each patient by consciously acknowledging your own values and
biases, developing communication skills that transcend cultural differences, and
building therapeutic partnerships based on respect for each patient’s life experi-
ence. This type of framework, described in the next section, will allow you to
approach each patient as a unique individual.

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The Three Dimensions of Cultural Humility

1. Self-awareness. Learn about your own biases; we all have them.
2. Respectful communication. Work to eliminate assumptions about what is “nor-

mal.” Learn directly from your patients; they are the experts on their culture

and illness.

3. Collaborative partnerships. Build your patient relationships on respect and
mutually acceptable plans.

Self-Awareness. Start by exploring your own cultural identity. How do you
describe yourself in terms of ethnicity, class, region or country of origin, religion,
and political affiliation? Don’t forget the characteristics we often take for granted—
gender, life roles, sexual orientation, physical ability, and race—especially if we
belong to majority groups. What aspects of your family of origin do you identify
with, and how are you different from your family of origin? How do these iden-
tities influence your beliefs and behaviors?

A more challenging task is to bring our own values and biases to a conscious
level. Values are the standards we use to measure our own and others’ beliefs and
behaviors. Biases are the attitudes or feelings that we attach to perceived differ-
ences. Being attuned to difference is normal; in fact, in the distant past, reacting
to differences may have ensured survival. Instinctively knowing members of
one’s own group is a survival skill that we may have outgrown as a society, but
that is still actively at work.

Feeling guilty about our biases makes them hard to recognize and acknowledge.
Start with less threatening constructs, like the way an individual relates to time,
a culturally determined phenomenon. Are you always on time—a positive value
in the dominant Western culture? Or do you tend to run a little late? How do you
feel about people whose habits are opposite to yours? Next time you attend a
meeting or class, notice who is early, on time, or late. Is it predictable? Think
about the role of physical appearance. Do you consider yourself thin, mid-size,
or heavy? How do you feel about your weight? What does prevailing U.S. culture
teach us to value in physique? How do you feel about people who have different
weights?

Respectful Communication. Given the complexities of global society,
no one can possibly know the health beliefs and practices of every culture and
subculture. Let your patients be the experts on their own unique cultural per-
spectives. Even if patients have trouble describing their values or beliefs, they
can often respond to specific questions. Find out about the patient’s cultural
background. Maintain an open, respectful, and inquiring attitude. “What did
you hope to get from this visit?” If you have established rapport and trust,
patients will be willing to teach you. Be aware of questions that contain
assumptions. And always be ready to acknowledge your areas of ignorance or
bias. “I know very little about Ghana. What would have happened at a clinic
there if you had these concerns?” Or, with the second patient and with much
more difficulty, “I mistakenly made assumptions about you that are not right.

Use some of the same questions

discussed earlier in Sharing the

Treatment Plan, pp. 80–81.

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I apologize. Would you be willing to tell me more about yourself and your
future goals?”

Learning about the patient’s specific culture broadens the areas you, as a clini-
cian, need to explore. Do some reading about the life experiences of individuals
in ethnic or racial groups who live in your area. There may be historic reasons
for loss of trust in clinicians or health care.60 Go to movies filmed in foreign
countries, which can help you better understand different cultures. Learn about
the explicit health agendas of different consumer groups. Talk with different
kinds of healers and learn about their practices. Most importantly, be open to
learning from each patient. Do not assume that your impressions about a given
cultural group apply to the individual before you.

Collaborative Partnerships. Through continual work on self-awareness
and seeing through the “lens” of others, the clinician lays the foundation for the
collaborative relationship that best supports the patient’s health. Communication
based on trust, respect, and your own willingness to re-examine assumptions
allows patients to be more open to expressing views that diverge from the dom-
inant culture. They may have strong feelings such as anger or shame. You, the
clinician, must be willing to listen to and validate these emotions, and not let
your own feelings of discomfort or time pressure prevent you from exploring
painful areas. Be willing to re-examine your beliefs about the “right approach” to
clinical care in a given situation. Make every effort to be flexible as you develop
shared plans that reflect patients’ knowledge about their best interests that are
congruent with both their beliefs and effective clinical care. Remember that if
the patient stops listening, fails to follow your advice, or does not return, your
care has not been successful.

Advanced Interviewing

Interviewing the Challenging Patient

As you spend time inviting patient stories, you will find that some patients are more
difficult to interview than others. For some clinicians, a quiet patient might seem
difficult, for others, a patient who is more assertive. Being aware of your reactions
helps develop your clinical skills. Your success in eliciting the history from different
types of patients grows with experience, but take into account your own stressors,
such as fatigue, mood, and overwork. Self-care is also important in caring for others.
Even if a patient is challenging, always remember the importance of listening to the
patient and clarifying his or her concerns.

The Silent Patient. Novice interviewers often feel uncomfortable with
periods of silence and try to keep the conversation going. Silence has many
meanings. Patients fall silent to collect their thoughts, remember details, or
decide if they can trust you with certain information. Periods of silence usually
seem longer to the clinician than the patient. Be attentive and respectful, and
encourage the patient to continue when ready. Watch the patient closely for
nonverbal cues, such as difficulty controlling emotions. Being comfortable

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See Chapter 5, Behavior and Mental

Status, pp. 147–171.

See Chapter 5, Behavior and Mental

Status, Medically Unexplained Symp-

toms, pp. 149–150, and Table 5-1,

Somatic Symptom and Related

Disorders, p. 169.

with periods of silence may be therapeutic, prompting the patient to reveal
deeper feelings.

Patients with depression or dementia may seem subdued and lose their usual
affect, giving only short answers to questions, then falling silent. If you have
already tried guided questioning, try shifting to more direct inquiry about symp-
toms of depression, or begin an exploratory mental status examination.

At times, silence may be the patient’s response to how you are asking questions.
Are you asking too many short-answer questions in rapid succession? Have you
offended the patient by showing disapproval or criticism? Have you failed to
recognize an overwhelming symptom such as pain, nausea, or shortness of
breath? If so, you may need to ask the patient directly, “You seem very quiet.
Have I done something to upset you?”

The Confusing Patient. Some patient stories are confusing and do not
seem to make sense. Just as you develop a differential diagnosis from the symp-
toms of the Present Illness, keep several possibilities in mind as you assess why
the story is confusing. It may be the patient’s style, and by using your skills of
guiding questions, clarification, and summarizing, you can put together a
coherent story. Watch for an underlying issue, however, that is interfering with
communication.

Some patients present a confusing array of multiple symptoms. They seem to
have every symptom that you ask about, or “a positive review of systems.”
With these patients, focus on the context of the symptom, emphasizing the
patient’s perspective (see pp. 77–78), and guide the interview into a psycho-
social assessment.

At other times, you may feel baffled and frustrated because the history is vague,
and ideas are poorly connected and hard to follow. Even with careful wording,
you cannot prompt clear answers to your questions. The patient may seem pecu-
liar, distant, aloof, or inappropriate. Symptoms may seem bizarre: “My fingernails
feel too heavy” or “My stomach knots up like a snake.” Perhaps there is a mental
status change like psychosis or delirium, a mental illness such as schizophrenia,
or a neurologic disorder. Consider delirium in acutely ill or intoxicated patients
and dementia in the elderly. Their histories are inconsistent and dates are hard to
follow. Some may even confabulate to fill in the gaps in their memories.

If you suspect a psychiatric or neurologic disorder, gathering a detailed history
can tire and frustrate both you and the patient. Shift to the mental status exami-
nation, focusing on level of consciousness, orientation, memory, and capacity to
understand. You can ease this transition by asking questions like “When was
your last appointment at the clinic? Let’s see . . . that was about how long ago?”
“Your address now is . . . ? . . . and your phone number?” You can confirm these
responses in the chart or ask permission to speak with family members or friends
to obtain their perspectives.

The Patient with Altered Cognition. Some patients cannot provide
their own histories because of delirium, dementia, or mental health conditions.

See Table 20-2, Delirium and

Dementia, p. 1001.

See Chapter 5, Behavior and Mental

Status, The Mental Status Examina-

tion, pp. 147–171.

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Others are unable to remember certain parts of the history, such as events
related to a febrile illness or a seizure. Under these circumstances, you will need
to obtain historical information from other sources such as family members or
caregivers. Always seek the best-informed source. Apply the basic principles of
interviewing to your conversations with relatives or friends. Find a private place
to talk. Introduce yourself, state your purpose, inquire how they are feeling
under the circumstances, and recognize and acknowledge their concerns. As
you listen to their accounts, assess their credibility in light of the quality of their
relationship with the patient. Establish how they know the patient. For example,
when a child is brought in for health care, the accompanying adult may not
be the parent or caregiver, but just the most available driver. Remember that
while you are gathering information about the history, you should not disclose
information about the patient unless the informant is the health care proxy or
has a durable power of attorney for health care, or you have permission from
the patient. Learn the tenets of the Health Insurance Portability and
Accountability Act (HIPAA) passed by Congress in 1996, which sets strict
standards for disclosure for both institutions and providers when sharing
patient information.61

Some patients can provide a history, but lack the ability to make informed health
care decisions. You then need to determine whether a patient has “decision-
making capacity,” which is the ability to understand information related to health,
weigh choices and their consequences, reason through the options, and commu-
nicate a choice. Capacity is a clinical designation and can be assessed by clinicians,
whereas competence is a legal designation and can only be decided by a court. If a
patient lacks capacity to make a health care decision, then identify the health care
proxy or the agent with power of attorney for health care. If the patient had not
identified a surrogate decision-maker, then that role may shift to a spouse or
family member. It is critical to remember that decision-making capacity is both
“temporal and situational”:62 It can fluctuate depending on the condition of the
patient and the complexity of the decision involved. A patient who is quite ill
may be unable to make decisions about care, but can regain capacity with clini-
cal improvement. A patient may be unable to make a complex decision, but still
able to make simple decisions. Even if patients lack capacity for certain deci-
sions, it is still important to seek their input, as they may have definite opinions
about their care.

Elements of Decision-Making Capacity

Patients must have the ability to:

● Understand the relevant information about proposed diagnostic tests or

treatment,
● Appreciate their situation (including their underlying values and current

clinical situation),
● Use reason to make a decision, and
● Communicate their choice.

Source: Sessums LL, Zembrzuska H, Jackson JL. Does This Patient Have Medical Decision-Making

Capacity? JAMA. 2011;306:420.

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The Aid to Capacity Evaluation (ACE)63 is an instrument that has been validated
against a gold standard, is free and available online, can be performed in less than
30 minutes, and uses the patient’s actual clinical scenario in the evaluation.

The Talkative Patient. The garrulous rambling patient is also challenging.
Faced with limited time to “get the whole story,” you may grow impatient, even
exasperated. Although this problem has no perfect solution, several techniques
are helpful. Give the patient free rein for the first 5 or 10 minutes, while listening
closely. Perhaps the patient simply needs a good listener and is expressing
pent-up concerns, or just enjoys telling stories. Does the patient seem obsessively
detailed? Is the patient unduly anxious or apprehensive? Is there flight of ideas
or a disorganized thought process that suggests a thought disorder?

Focus on what seems most important to the patient. Show your interest by ask-
ing questions in those areas. Interrupt only if necessary, but be courteous. Learn
to set limits when needed, since part of your task is structuring the interview to
gain important information about the patient’s health. A brief summary may help
you change the subject, yet validate any concerns. “Let me make sure that I
understand. You have described many concerns. In particular, I heard about two
different kinds of pain, one on your left side that goes into your groin and is fairly
new, and one in your upper abdomen after you eat that you have had for months.
Let’s focus just on the side pain first. Can you tell me what it feels like?” Or you
can ask the patient, “What is your #1 concern today?”

Finally, avoid showing impatience. If time runs out, explain the need for a sec-
ond visit and prepare the patient by setting a time limit. “I know we have much
more to talk about. Can you come again next week? We will have a 30-minute
visit then.”

The Crying Patient. Crying signals strong emotions, ranging from sadness
to anger or frustration. Pausing, gentle probing, or responding with empathy
gives the patient permission to cry. Usually crying is therapeutic, as is your quiet
acceptance of the patient’s distress. Offer a tissue and wait for the patient to
recover. Make a supportive remark like “I am glad you were able to express your
feelings.” Most patients will soon compose themselves and resume their story.
Crying makes many clinicians uncomfortable. If this is true for you, learn how
to accept displays of emotion so you can support patients at these moving and
significant times.

The Angry or Disruptive Patient. Many patients have reasons to be
angry: They are ill, they have suffered a loss, they have lost control of their health,
or they feel overwhelmed by the health care system.26 They may direct this anger
toward you. It is possible that their anger at you is justified . . . were you late
for your appointment, inconsiderate, insensitive, or angry yourself? If so,
acknowledge the situation and try to make amends. More often, however,
patients displace their anger onto the clinician as a reflection of their frustration
or pain.

Learn to accept angry feelings from patients without getting angry in return or
retreating from the patient’s affect.64 Avoid reinforcing criticism of other clinicians,

See Summarization, p. 72.

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the clinical setting, or the hospital, even if you feel sympathetic. You can validate
patients’ feelings without agreeing with their reasons. “I understand that you felt
frustrated by answering the same questions over and over. Repeating the same
information to everyone on the team can seem unnecessary when you are sick.”
After the patient has calmed down, help the patient to work through his or her
angry feelings and move on to other concerns.

Some angry patients become overtly disruptive, belligerent, or out of control.
Before approaching such patients, alert the security staff; ensuring a safe environ-
ment is one of your responsibilities. Stay calm and avoid being confrontational.
Keep your posture relaxed and nonthreatening. At first, do not try to make dis-
ruptive patients lower their voices or stop threatening you or the staff. Listen
carefully. Try to understand what they are saying. Once you have established
rapport, gently suggest moving to a more private location.

The Patient with a Language Barrier. Nothing makes the importance of
the history more evident than being unable to communicate with the patient, an
increasingly common experience. In 2011, the Census Bureau reported that more
than 60 million Americans speak a language other than English at home. Of these,
more than 20% have limited English proficiency. Spanish is the primary non-English
language, spoken by 37 million Americans.65 These individuals are less likely to have
regular primary or preventive care and more likely to experience dissatisfaction and
adverse outcomes from clinical errors. Learning to work with qualified interpreters is
essential for optimal outcomes and cost-effective care.66–70 Experts take this one step
further, “If it isn’t culturally and linguistically appropriate, it isn’t health care.”71

If your patient speaks a different language, make every effort to find a trained
interpreter. A few words of clinical Spanish may enhance rapport, but they are
no substitute for the full story. Even if you are fluent, you may miss important
nuances in the meanings of certain words.72 Recruiting family members as
translators is equally hazardous—it may violate confidentiality, and information
may be incomplete, misleading, or harmful. Lengthy patient explanations may
be telescoped into a few words, omitting significant details. The ideal inter-
preter is a “cultural navigator” who is neutral and trained in both languages and
cultures.73,74 However, even trained interpreters may be unfamiliar with the
multiple subcultures in many societies.

When you work with an interpreter, begin by establishing rapport and reviewing
the information that will be most useful. Ask the interpreter to translate everything,
not to condense or summarize. Make your questions clear, short, and simple. Help
the interpreter by outlining your goals for each segment of the history. After going
over your plans, arrange the seating so that you have easy eye contact with the
patient. Then speak directly to the patient… “How long have you been sick?” rather
than “How long has the patient been sick?” Having the interpreter sit close to the
patient, or even behind you, keeps you from turning your head back and forth.

When available, bilingual written questionnaires are invaluable, especially for
the review of systems. First, however, be sure that patients can read in their lan-
guage; otherwise, ask the interpreter for help. In some clinical settings, use
speakerphone translators, if available.

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Guidelines for Working with an
Interpreter: “INTERPRET”

I Introductions: Make sure to introduce all the individuals in the room. Dur-
ing the introduction, include information as to the roles individuals will play.

N Note Goals: Note the goals of the interview. What is the diagnosis? What
will the treatment entail? Will there be any follow-up?

T Transparency: Let the patient know that everything said will be inter-
preted throughout the session.

E Ethics: Use qualified interpreters (not family members or children) when
conducting an interview. Qualified interpreters allow the patient to

maintain autonomy and make informed decisions about his or her care.

R Respect Beliefs: Limited English Proficient (LEP) patients may have cultural
beliefs that need to be taken into account as well. The interpreter may be able

to serve as a cultural broker and help explain any cultural beliefs that may exist.

P Patient Focus: The patient should remain the focus of the encounter.
Providers should interact with the patient and not the interpreter. Make

sure to ask and address any questions the patient may have before end-

ing the encounter. If you don’t have trained interpreters on staff, the

patient may not be able to call in with questions.

R Retain Control: It is important as the provider that you remain in control
of the interaction and not let the patient or the interpreter take over the

conversation.

E Explain: Use simple language and short sentences when working with an
interpreter. This will ensure that comparable words can be found in the

second language and that all the information can be conveyed clearly.

T Thanks: Thank the interpreter and the patient for their time. On the
chart, note that the patient needs an interpreter and who served as an

interpreter this time.

Source: U.S. Department of Health and Human Services. INTERPRET tool: working with interpret-

ers in cultural settings. Available at https: www.google.com/#q = USDHHS+Interpret+Tool.
Accessed January 11, 2015.

The Patient with Low Literacy or Low Health Literacy. Before
giving written instructions, assess the patient’s ability to read. More than 14% of
Americans, or 30 million people, are unable to read basic documents.75 Low
literacy may explain why the patient has not taken medications or followed your
recommendations.

To detect low literacy, you can ask about years completed in school, or “How is
your reading?” You can ask “How comfortable are you with filling out health
forms?” or check how well the patient reads written instructions. One rapid
screen is to hand the patient a written text upside down—most patients will turn
the page around immediately. Many patients are embarrassed about reading
poorly. Be sensitive to their quandary, and do not confuse their degree of literacy
with level of intelligence. Explore the reasons for impaired literacy—language
barriers, learning disorders, poor vision, or level of education.

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Research shows that low health literacy, affecting 80 million Americans, leads to
poor health outcomes and impaired use of health services.76 Health literacy goes
beyond just reading. It includes the practical skills the patient needs to navigate
the health care environment: print literacy, or the ability to interpret information
in documents; numeracy, or the ability to use quantitative information for tasks
like interpreting food labels or adhering to medication regimens; and oral literacy,
or the ability to speak and listen effectively.

The Patient with Hearing Loss. Approximately 9% of the U.S. population
is deaf or hard of hearing. This population “is a heterogeneous group that includes
persons who have varying degrees of hearing loss, use multiple languages, and
belong to different cultures. Solutions to providing health care to one group from
(this) population do not necessarily apply to the other groups. Factors that must
be considered with this population include degree of hearing loss, age of onset of
loss, preferred language, and psychological issues.”77 Communication and trust
are special challenges, and the risk of mis communication is high.78 Even hearing-
impaired patients who use English may not follow standard English usage.

Find out the patient’s preferred method of communication. Learn whether the
patient belongs to the deaf culture or the hearing culture, when the hearing
loss occurred relative to the development of speech and language, and the
kinds of schools the patient attended. Review responses to written question-
naires. Patients may use American Sign Language (ASL), a unique language with
its own syntax. These patients typically have a low English reading level and
prefer having certified ASL interpreters present during their visits.77 Other
patients may use varying combinations of signs and speech. If working with an
interpreter, adopt the principles identified earlier. Alternatively, time-consuming
handwritten questions and answers may be the only solution.

Partial hearing deficits vary. If the patient has a hearing aid, find out if the
patient is using it. Make sure it is working. For patients with unilateral hearing
loss, sit on the hearing side. A person who is hard of hearing may not be aware
of the problem, a situation you will have to address tactfully. Eliminate back-
ground noise from the television or hallway. Face patients who can read lips
directly, in good light. Patients should put on their glasses to see cues that help
them understand you. Speak at a normal volume and rate. Avoid letting your
voice trail off at the ends of sentences, covering your mouth, or looking down
at papers while speaking. Emphasize key points first. Even the best lip readers
comprehend only a part of what you say, so asking them to “teach back” is
important. When closing, write out your instructions for them to take home.

The Patient with Impaired Vision. With blind patients, shake hands
to establish contact and explain who you are and why you are there. If the room
is unfamiliar, orient the patient to the surroundings and report if anyone else is
present. If helpful, adjust the light. Encourage visually impaired patients to wear
glasses whenever possible. Spend more time on verbal explanations because
postures and gestures are unseen.

The Patient with Limited Intelligence. Patients of moderately limited
intelligence can usually give adequate histories. If you suspect a disability, pay

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special attention to the patient’s school record and ability to function
independently. How far have such patients gone in school? If they didn’t finish,
why not? What kinds of courses have they taken? How did they do? Has any
testing been done? Are they living alone? Do they need assistance with activities
like transportation or shopping? The sexual history is equally important and
often overlooked. Find out if the patient is sexually active and provide information
about pregnancy or sexually transmitted infections (STIs), if needed.

If you are unsure about the patient’s level of intelligence, transition to the mental
status examination and assess simple calculations, vocabulary, memory, and
abstract thinking.

For patients with severe mental retardation, turn to family or caregivers for the
history, but always show interest in the patient first. Establish rapport, make eye
contact, and engage in simple conversation. As with children, avoid “talking
down” or condescending behavior. The patient, family members, caregivers, or
friends will appreciate your respect.

The Patient with Personal Problems. Patients may ask you for advice
about personal problems that fall outside the range of your clinical expertise.
Should the patient quit a stressful job, for example, or move out of state? Instead
of responding, ask about what alternatives that the patient has considered, related
pros and cons, and others who have provided advice. Letting the patient talk
through the problem with you is more therapeutic than giving your own opinions.

The Seductive Patient. Clinicians occasionally find themselves physically
attracted to their patients. Similarly, patients may make sexual overtures or
exhibit flirtatious behavior. The emotional and physical intimacy of the clinician–
patient relationship can lend itself to these sexual feelings.

If you become aware of such feelings, bring them to conscious level to keep them
from affecting your professional behavior. Denial can heighten the risk of
responding inappropriately. Any sexual contact or romantic relationship with
patients is unethical; keep your relationship with the patient within professional
bounds, and seek help if you need it.79–82

When patients are seductive, you may be tempted to ignore their behavior because
you are not sure it really happened, or you are just hoping it will go away. Calmly
but firmly set clear limits that your relationship is professional, not personal. If
necessary, leave the room and find a chaperone before you continue the visit.
Think carefully about your own behavior. Has your clothing or demeanor been
inappropriate? Have you been overly warm with the patient? It is your responsi-
bility to evaluate and avoid sending any misleading signals to the patient.

Sensitive Topics

Clinicians talk with patients about many sensitive topics. These discussions can
be awkward when you are inexperienced or assessing patients you do not know
well. Even seasoned clinicians are inhibited by societal constraints when discuss-
ing certain subjects: abuse of alcohol or drugs, sexual practices, death and dying,

See Chapter 5, Behavior and Mental

Status, pp. 147–171.

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financial concerns, racial and ethnic bias, domestic violence, psychiatric illness,
physical deformity, bowel function, and others. Many of these topics trigger
strong personal responses related to family, cultural, and societal values. Mental
illness, drug use during pregnancy, and same-sex practices are examples of issues
that may evoke biases that affect your interaction with the patient (Fig. 3-9).

Several basic principles can help guide your response to sensitive topics:

F I G U R E 3 – 9 . Maintain a

nonjudgmental manner.

Guidelines for Broaching Sensitive Topics

● The single most important rule is to be nonjudgmental. Your role is to learn from
the patient and help the patient achieve better health. Acceptance is the best

way to reach this goal.
● Explain why you need to know certain information. This makes patients less

apprehensive. For example, say to patients, “Because sexual practices put

people at risk for certain diseases, I ask all of my patients the following

questions.”
● Find opening questions for sensitive topics and learn the specific kinds of

information needed for your shared assessment and plan.
● Consciously acknowledge whatever discomfort you are feeling. Denying your

discomfort may lead you to avoid the topic altogether.

Look into strategies that help make you more comfortable when discussing sensitive
areas. These include reading about these topics in clinical and lay literature; talking
with colleagues and teachers about your concerns; taking courses that help you
explore your feelings and reactions; and ultimately, reflecting on your own life expe-
rience. Take advantage of all these resources. If possible, listen to experienced clini-
cians as they approach these issues with patients, then practice similar techniques
in your own discussions. Over time, your level of comfort will grow and expand.

The Sexual History. Exploring the sexual history can be life-saving. Sexual
behaviors determine risks for pregnancy, STIs, and human immunodeficiency
virus (HIV); good interviewing helps prevent or reduce these risks.83,84 Sexual
practices may be directly related to the patient’s symptoms and integral to both
diagnosis and treatment. Many patients express their concerns more freely when
you ask about sexual health. In addition, sexual dysfunction may result from
medications or clinical issues that can be readily corrected.

You can elicit the sexual history at multiple points in the interview. If the chief
complaint involves genitourinary symptoms, include questions about sexual
health as part of “expanding and clarifying” the patient’s story. For women,
you can ask these questions during the Obstetric/Gynecologic section of the
Past Medical History. You can include the sexual history in discussions about
Health Maintenance, or in the Personal and Social History as you explore
lifestyle issues and important relationships. In a comprehensive history, you
can also ask about sexual practices during the Review of Systems. Do not
forget to cover the sexual history in older patients and patients with disability
or chronic illness.

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An orienting sentence or two is often helpful. “To assess your risk for various
diseases, I need to ask you some questions about your sexual health and prac-
tices” or “I routinely ask all patients about their sexual function.” For more
specific complaints you might state, “To figure out why you have this discharge and
what we should do, I need to ask some questions about your sexual activity.” If you
are matter-of-fact, the patient is more likely to follow your lead. Use specific language.
Refer to genitalia with explicit words such as penis or vagina and avoid phrases like
“private parts.” Choose words that are understandable and explain what you mean.
“By intercourse, I mean when a man inserts his penis into a woman’s vagina.”

Also ask about satisfaction with sexual activity. Review the examples of questions
that follow. These questions are designed to help patients reveal their concerns.

The Sexual History: Sample Questions

● “When was the last time you had intimate physical contact with someone?”

“Did that contact include sexual intercourse?” The term “sexually active” can

be ambiguous. Patients have been known to reply, “No, I just lie there.”
● “Do you have sex with men, women, or both?” Patients may have same-sex

partners, yet not consider themselves gay, lesbian, or bisexual. Some gay and

lesbian patients have had opposite-sex partners.
● “How many sexual partners have you had in the last 6 months? In the last

5 years? In your lifetime?” These questions make it easy for the patient to

acknowledge multiple partners. Ask, “Have you had any new partners in the

past 6 months?” If patients question why this information is important,

explain that new partners or multiple partners over a lifetime can raise the

risk for STIs. Ask about routine use of condoms. “How often do you use

condoms?” is an open-ended question that does not presume an answer.
● It is important to ask all patients, “Do you have any concerns about HIV

infection or AIDS?” since infection can occur in the absence of risk factors.

Note that these questions make no assumptions about marital status, sexual
preference, or attitudes about pregnancy or contraception. Listen to each of the
patient’s responses, and invite additional history as indicated. To elicit informa-
tion about sexual behaviors, you will need to ask more specific and focused
questions than in other parts of the interview.

The Mental Health History. Cultural constructs of mental and
physical illness vary widely, leading to differences in social acceptance and
attitudes. Think how easy it is for patients to talk about diabetes and taking
insulin compared with discussing schizophrenia and using psychotropic
medications. Ask open-ended questions initially. “Have you ever had any
problem with emotional or mental illnesses?” Then move to more specific
questions such as “Have you ever seen a counselor or psychotherapist?” “Have
you ever taken medication for a mental health condition?” “Have you ever
been hospitalized for an emotional or mental health problem?” “What about
members of your family?”

See specific questions in Chapter 13,

Male Genitalia and Hernias, pp. 541–

563, and Chapter 14, Female Genitalia,

pp. 565–606.

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For patients with depression or thought disorders such as schizophrenia, take a
careful history of their symptoms and course of illness. Watch for mood changes
or symptoms such as fatigue, unusual tearfulness, appetite or weight changes,
insomnia, and vague somatic complaints. Two validated screening questions for
depression are: “Over the past 2 weeks, have you felt down, depressed, or hope-
less?” and “Over the past 2 weeks, have you felt little interest or pleasure in
doing things?”85 If the patient seems depressed, always ask about suicide: “Have
you ever thought about hurting yourself or ending your life?” As with chest pain,
you must evaluate severity—both depression and angina are potentially lethal.

Many patients with psychotic disorders like schizophrenia are living in the
community and can tell you about their diagnoses, symptoms, hospitalizations,
and current medications. Investigate whether their symptoms and level of func-
tion are stable and review their support systems and plan of care.

Alcohol and Prescription and Illicit Drugs. Many clinicians hesitate
to ask patients about excess use of alcohol and prescribed or illicit drugs. The
prevalence of substance abuse and dependence remains high. In 2013, 21.6
million Americans, or 8.2% of persons aged 12 years and older, were classified
with a substance abuse or dependence disorder, including 14.7 million people
with alcohol abuse or dependence, 2.6 million with alcohol and illicit drug
abuse or dependence, and 4.3 million with illicit drug abuse or dependence.
Abuse of prescribed pain medications is also increasing, now numbering
about 1.9 million people.86 Roughly 28% of Americans aged 12 years or older
report binge or heavy drinking, and almost 3%, or 7 million, have used
prescription drugs for nonclinical reasons, especially pain relievers, stimulants,
and antidepressants.39,87,88 The high prevalence of substance abuse makes it is
essential to routinely assess current and past use of alcohol and drugs, patterns
of use, and family history. Be familiar with current definitions of addiction,
dependence, and tolerance.

Turn to Chapter 5, Behavior and Mental

Status, for discussions of depression,

suicidality, and psychotic disorders,

pp. 147–171.

Addiction, Physical Dependence, and Tolerance

Tolerance: A state of adaptation in which exposure to a drug induces changes
that result in a diminution of one or more of the drug’s effects over time.

Physical Dependence: A state of adaptation that is manifested by a drug class-
specific withdrawal syndrome that can be produced by abrupt cessation,

rapid dose reduction, decreasing blood level of the drug, and/or administra-

tion of an antagonist.

Addiction: A primary, chronic, neurobiologic disease, with genetic, psychoso-
cial, and environmental factors influencing its development and manifesta-

tions. It is characterized by behaviors that include one or more of the

following: impaired control over drug use, compulsive use, continued use

despite harm, and craving.

Source: American Pain Society. Definitions Related to the Use of Opioids for the Treatment of

Pain. A consensus statement from the American Academy of Pain Medicine, the American Pain

Society, and the American Society of Addiction Medicine, 2001. Available at http://www.asam.

org/docs/public-policy-statements/1opioid-definitions-consensus-2–011.pdf?sfvrsn=0. Accessed
January 13, 2015.

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Alcohol. Questions about alcohol and other drugs follow naturally after
questions about caffeine and cigarettes. “Tell me about your use of alcohol” is an
opening query that avoids the easy yes-no response. Remember that some
patients do not consider wine or beer as “alcohol.” Positive answers to two addi-
tional questions are highly suspicious for problem-drinking: “Have you ever had
a drinking problem?” and “When was your last drink?”, especially if the night
before.89 The most widely used screening questions are the CAGE questions
about Cutting down, Annoyance when criticized, Guilty feelings, and Eye-
openers. The CAGE Questionnaire is readily available online.

Two or more affirmative answers to the CAGE Questionnaire suggest alcohol
misuse and have a sensitivity that ranges from 43% to 94% and specificity ranging
from 70% to 96%.90,91 Several well-validated short screening tests, such as the
MAST (Michigan Alcohol Screening Test) and the AUDIT (Alcohol Use Disorders
Identification Test), are also helpful.92 If you detect misuse, ask about blackouts
(loss of memory about events during drinking), seizures, accidents or injuries
while drinking, job problems, and conflict in personal relationships.

Illicit Drugs. The National Institute on Drug Abuse recommends first ask-
ing a highly sensitive and specific single question: “How many times in the past
year have you used an illegal drug or used a prescription medication for non-
clinical reasons?”93,94 If there is a positive response, ask specifically about non-
clinical use of illicit and prescription drugs: “In your lifetime have you ever used:
marijuana; cocaine; prescription stimulants; methamphetamines; sedatives or
sleeping pills; hallucinogens like lysergic acid diethylamide (LSD), ecstasy,
mushrooms…; street opioids like heroin or opium; prescription opioids like
fentanyl, oxycodone, hydrocodone…; or other substances.” For those answering
yes, a series of further questions is recommended.93

Another approach is to modify the CAGE questions by adding “or drugs” to each
question. Once you identify substance abuse, probe further with questions like
“Are you always able to control your use of drugs?” “Have you had any bad reac-
tions?” “What happened . . . Any drug-related accidents, injuries, or arrests? Job
or family problems?” . . . “Have you ever tried to quit? Tell me about it.”

Intimate Partner Violence and Domestic Violence. Intimate partner
violence is the leading cause of serious injury and the second leading cause of death
among U.S. women of reproductive age.95 Each year, more than 12 million U.S.
women and men experience rape, physical violence, or stalking by an intimate
partner; these are groups that experience high rates of mental health disorders and
substance abuse.96,97 Prevalence varies from 20% in general practice settings to over
30% in emergency rooms and orthopedic clinics.98–100 The U.S. Preventive Services
Task Force and the American College of Obstetricians and Gynecologist recommend
routine screening of all women of childbearing age for intimate partner violence
and providing or referring those who screen positive for intervention services.101,102
Elders are also highly vulnerable to neglect and abuse.103–105

Sensitive interviewing is essential, since even with skilled inquiry, only 25%
of patients disclose their abuse experience.106,107 The type of questioning is
important. Experts recommend beginning with normalizing statements such as

National Institute of Alcohol Abuse

and Alcoholism Definitions of Drink-

ing at Low Risk for Developing and

Alcohol Use Disorder

● Men: no more than 4 drinks on a

single day or 14 drinks a week

● Women: no more than 3 drinks on a

single day or 7 drinks a week

● Healthy adults over age 65 years

and not taking medications: no

more than 3 drinks on a single day

or 7 drinks a week

● 1 drink is defined as 12 ounces of

beer, 5 ounces of wine, or 1.5 ounces

of spirits

Source: National Institute of Alcohol Abuse

and Alcoholism, Drinking levels defined. Avail-

able at http://www.niaaa.nih.gov/alcohol-

health/overview-alcohol-consumption/

moderate-binge-drinking. Accessed January 14,

2015.

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“Because abuse is common in many women’s lives, I’ve begun to ask about it
routinely.” Disclosure is more likely when probing questions lead and then in-
depth direct questions follow. “Are you in a relationship where you have been hit
or threatened?” with a pause to encourage the patient to respond. If the patient
says no, continue with “Has anyone ever treated you badly or made you do
things you don’t want to?” or “Is there anyone you are afraid of?” or “Have you
ever been hit, kicked, punched, or hurt by someone you know?” Following
disclosure, empathic validating and nonjudgmental responses are critical, but
currently occur less than half the time.

Clues to Physical and Sexual Abuse. Be alert to the unspoken clues to
abuse, often present in the growing numbers of victims of human sex trafficking
in the United States and internationally, estimated at 50,000 women and chil-
dren annually in the United States alone.108,109

See also Chapter 18, Assessing Chil-

dren, Infancy Through Adolescence,

Table 18-11, Physical Signs of Sexual

Abuse, p. 921.

Clues to Physical and Sexual Abuse

● Injuries that are unexplained, seem inconsistent with the patient’s story, are

concealed by the patient, or cause embarrassment
● Delay in getting treatment for trauma
● History of repeated injuries or “accidents”
● Presence of alcohol or drug abuse in patient or partner
● Partner tries to dominate the visit, will not leave the room, or seems unusually

anxious or solicitous
● Pregnancy at a young age; multiple partners
● Repeated vaginal infections and STIs
● Difficulty walking or sitting due to genital/anal pain
● Vaginal lacerations or bruises
● Fear of the pelvic examination or physical contact
● Fear of leaving the examination room

See Chapter 18, Assessing Children:

Infancy Through Adolescence,

pp. 799–925.

When you suspect abuse, it is important to spend part of the visit alone with the
patient. You can use the transition to the physical examination as a reason to ask
others to leave the room. If the patient is also resistant, do not force the situation,
potentially placing the victim in jeopardy. Be attuned to diagnoses that have a
higher association with abuse, such as pregnancy and somatic symptom disorder.

To begin screening for child abuse, ask parents about their approach to discipline.
Ask how they cope with a baby who will not stop crying or a child who misbe-
haves: “Most parents get very upset when their baby cries (or their child has been
naughty). How do you feel when your baby cries?” “What do you do when your
baby won’t stop crying?” “Do you have any fears that you might hurt your child?”

Death and the Dying Patient. There is a growing and important emphasis
in health care education on improving care for dying patients and their families.
Many studies have advanced our understanding of palliative care and set standards
for quality care.110,111 Even as beginning students, working through your own
feelings about death and dying and acquiring basic skills to ensure good

For discussion of end-of-life decision-

making, grief and bereavement, and

advance directives, turn to Chapter 20,

The Older Adult, pp. 975–976.

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ADVANCED INTERVIEWING

communication are important, as you will come into contact with patients of all
ages near the end of their lives. Studies show that clinicians are still not
communicating effectively with patients and families about how to manage
symptoms and their preferences for care. Clinician interventions that improve
symptoms and avoid hospitalization reduce grief and bereavement, improve
outcomes and quality of care, reduce costs, and sometimes even prolong
survival.111–113

For those facing death and their survivors, there are overlapping and sometimes
prolonged phases of anticipatory grief and bereavement.114 Kübler-Ross pro-
vided the classical description of the stages in our response to loss or the antic-
ipatory grief of impending death: denial and isolation, anger, bargaining,
depression or sadness, and acceptance.115 These stages may occur sequentially
or in any order or combination. Offer openings for patients and family members
to talk about their feelings and ask questions. As defined by the World Health
Organization, your goal is “the prevention and relief of suffering by means of
early identification and impeccable assessment and treatment of pain and other
problems, physical, psychosocial, and spiritual.”116 Ask, “I wonder if you have
concerns about your illness? . . . your pain? . . . your preferences for treatment?”
Provide the information requested and demonstrate your commitment to sup-
port and coordinate the patient’s care throughout the illness. Dying patients
rarely want to talk about their illnesses at each encounter, nor do they wish to
confide in everyone they meet. If they wish to stay at a social level, respect their
preferences. A smile, a touch, an inquiry about a family member, a comment on
the day’s events, or even gentle humor conveys your concern and responsiveness.

Clarifying the patient’s wishes about treatment at the end of life is an important
responsibility. Failing to facilitate end-of-life decision-making is widely viewed as
a flaw in clinical care. The health status of the patient and the health care setting
often determine what needs to be discussed. For patients who are acutely ill and
in the hospital, discussions about how to respond to a cardiac or respiratory arrest
are usually mandatory. Asking about Do Not Resuscitate (DNR) status is often diffi-
cult if you have not had a previous relationship with the patient or are unsure of
the patient’s understanding of the illness. The media give many patients an unre-
alistic view of the effectiveness of resuscitation. Explore, “What experiences have
you had with the death of a close friend or relative?” “What do you know about
cardiopulmonary resuscitation (CPR)?” Educate patients about the likely success
of CPR, especially if they are chronically ill or advanced in age. Assure them that
relieving pain and taking care of their spiritual and physical needs will be a priority.

In general, it is important to encourage any adult, but especially the elderly or
chronically ill, to establish a health proxy who can act as the patient’s health deci-
sion maker. This part of the interview can be a “values history” that identifies
what is important to the patient and makes life worth living, and when living
would no longer be worthwhile. Ask how patients spend their time every day,
what they enjoy, and what they look forward to. Make sure to clarify the meaning
of statements like, “You said that you don’t want to be a burden to your family.
What exactly do you mean by that?” Explore the patient’s religious or spiritual
beliefs so that you and the patient can make the most appropriate decisions
about health care.

See discussion of the Patient with

Altered Cognition, pp. 87–89.

100 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

ETHICS AND PROFESSIONALISM

Clinical ethics come into play scores of times each day in almost every patient
interaction.117–119 The power of clinician–patient communication calls for guid-
ance beyond our innate sense of morality.120 Ethics are a set of principles crafted
through reflection and discussion to define right and wrong. Clinical ethics, which
guide our professional behavior, are neither static nor simple, but several prin-
ciples have guided clinicians throughout the ages. Although often your sense of
right and wrong may be all that you need, even as students, you will face deci-
sions that call for the application of ethical principles.

Some of the traditional and still fundamental maxims embedded in the healing
professions are listed below. This body of ethics has been termed “principalism.”
As the field of clinical ethics expands, other ethical systems come in use: utili-
tarianism, or providing the greatest good for the greatest number, building on the
work of John Stuart Mill; feminist ethics, which invoke problems of marginaliza-
tion of social groups; casuistry, or the analysis of paradigmatic prior cases as rel-
evant; and communitarianism, which emphasizes the interests of communities
and societies over individuals and social responsibilities bearing on the need to
maintain the institutions of civil society.121

Building Blocks of Professional
Ethics in Patient Care

● Nonmaleficence or primum non nocere is commonly stated as, “First, do no
harm.” In the context of the interview, giving information that is incorrect or

not really related to the patient’s problem can do harm. Avoiding relevant

topics or creating barriers to open communication can also do harm.
● Beneficence is the dictum that the clinician acts in the best interest of the

patient.
● Autonomy reminds us that informed patients have the right to make their

own clinical decisions. This principle has become increasingly important over

time and is consistent with collaborative rather than paternalistic clinician–

patient relationships.
● Confidentiality can be one of the most challenging principles. As a clinician,

you are obligated not to repeat what you learn from or know about a patient.

This privacy is fundamental to our professional relationships with patients.

In the flurry of daily patient care, it is all too easy to let something slip. You

must be on your guard. Note that some frameworks posit Justice as the
fourth critical principle, namely that all patients be treated fairly with

equitable distribution of health care resources.122

Ethics and Professionalism

As students, you are exposed to some of the ethical challenges that you will
encounter later as practicing clinicians. However, there are dilemmas unique to
students that you will face from the time that you begin taking care of patients.
The following vignettes capture some common experiences. They raise a variety
of interconnected ethical and practical issues.

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ETHICS AND PROFESSIONALISM

Here you are confronted with the tension between the need to learn by doing and
doing no harm to patients. There is a utilitarian ethical principle that reminds us
that if clinicians-in-training do not learn, there will be no future caregivers. Yet,
the dictums to do no harm and prioritize what is in the patient’s best interests are
clearly in conflict with that future need. This dilemma will arise often while you
are a student.

The means to address this ethical dilemma is to obtain informed consent. Always
make sure the patient realizes that you are in training and new at patient evalu-
ation (Fig. 3-10). It is impressive how often patients willingly let students be
involved in their care; it is an opportunity for patients to give back to their care-
givers. Even when clinical activities appear purely for educational purposes,
there may be a benefit to the patient. Multiple caregivers provide multiple per-
spectives, and the experience of being heard and having a special advocate can
be therapeutic.

Ethics and Professionalism: Scenario 1

You are a third-year clinical student on your first clinical rotation in the hospital.

It is late in the evening when you are finally assigned to the patient you are to

“work up” and present the next day at preceptor rounds. You go to the patient’s

room and find the patient exhausted from the day’s events and ready to settle

down for the night. You know that your intern and attending physician have

already done their evaluations. Do you proceed with a history and physical that

is likely to take 1 to 2 hours? Is this process only for your education? Do you ask

permission before you start? What do you include?

F I G U R E 3 – 1 0 . Obtain informed

consent from patients when needed.

Ethics and Professionalism: Scenario 2

It is after 10 pm, and you and your resident are on the way to complete the

required advance directives form with a frail, elderly patient who was admitted

earlier that day with bilateral pneumonia. The form, which includes a discussion

of DNR orders, must be completed before the team can sign out and leave for

the day. Just then, your resident is paged to an emergency and asks you to go

ahead and meet with the patient to complete the form; the resident will cosign

it later. You had a lecture on advance directives and end-of-life discussions in

your first year of training, but have never seen a clinician discuss these issues

with a patient. You have not yet met the patient, nor have you had a chance to

really look at the form. What should you do? Do you inform the resident that

you have never done this before or even seen it done? Do you inform the patient

that this is totally new for you? Who should decide whether you are competent

to do this independently?

In this situation, you are being asked to take responsibility for clinical care that
exceeds your level of comfort and perhaps your competence. This can happen
in a number of situations, such as being asked to evaluate a clinical situation

102 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

ETHICS AND PROFESSIONALISM

without proper back-up or to draw blood or start an IV before practicing under
supervision. You may have many of the following thoughts about this patient:
“the patient needs to have this completed before going to sleep and so will ben-
efit”; “the risk to the patient from discussing advance directives is minimal”; “you
are pretty good with elderly patients and think that you might be able to do this”;
“what if the patient actually arrests that night and you are responsible for what
happens?”; and finally, “if you bother the resident now, he or she will be angry
and that may affect your evaluation.” There is educational value in being pushed
to the limits of your knowledge to solve problems and to gain confidence in
functioning independently. But what is the right thing to do in this situation?

The principles listed on page 100 only partially help you sort this out, because only
part of your quandary relates to your relationship with the patient. Much of the
tension in this scenario involves the dynamics of a health care team and your role
as a team member. You are there to help with the work, but you are primarily there
to learn. Current formulations of clinical ethics address those issues and others.
One such formulation is the Tavistock Principles.123 These principles construct a
framework for analyzing health care situations that extend beyond our direct care
of individual patients to complicated choices about the interactions of health care
teams and the distribution of resources for the well-being of society. A broadly
representative group, which initially met in Tavistock Square in London in 1998,
has continued to develop an evolving document of ethical principles for guiding
health care behavior for both individuals and institutions across the health care
spectrum. A current iteration of the Tavistock Principles follows.

The Tavistock Principles

Rights: People have a right to health and health care.
Balance: Care of the individual patient is central, but the health of populations is

also our concern.

Comprehensiveness: In addition to treating illness, we have an obligation to ease
suffering, minimize disability, prevent disease, and promote health.

Cooperation: Health care succeeds only if we cooperate with those we serve,
each other, and those in other sectors.

Improvement: Improving health care is a serious and continuing responsibility.
Safety: Do no harm.
Openness: Being open, honest, and trustworthy is vital in health care.

In the second scenario, think about the Tavistock Principles of openness and
cooperation, in addition to the balance between do no harm and beneficence. You
need to work with your team in a way that is honest and reliable to do the best
for the patient (Fig. 3-11). You can also see that there are no clear or easy answers
in such situations. What responses are available to you to address these and other
quandaries?

You need to reflect on your beliefs and assess your level of comfort with a given
situation. Sometimes there may be alternative solutions. For example, in Scenario 1,

F I G U R E 3 – 1 1 . Apply ethical

principles to difficult decisions.

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ETHICS AND PROFESSIONALISM

the patient may really be willing to have the history and physical examination
at that late hour, or perhaps you can negotiate a time for the next morning. In
Scenario 2, you might find another person who is more qualified to complete
the form or supervise you. Alternatively, you may choose to go ahead and
complete the form, focusing on open communication, and alerting the patient
to your inexperience while obtaining the patient’s consent. You will need to
choose when situations warrant voicing your concerns, even at the risk of a
bad evaluation.

Seek coaching on how to express your reservations in a way that ensures that
they will be heard. As a clinical student, you will need settings for discussing
these immediately relevant ethical dilemmas with other students and with more
senior trainees and faculty. Small groups that are structured to address these
kinds of issues are particularly useful in providing validation and support. Take
advantage of such opportunities whenever possible.

Ethics and Professionalism: Scenario 3

You are the student on the clinical team that has been taking care of Ms. Robbins,

a 64-year-old woman admitted for an evaluation of weight loss and weakness.

During the hospitalization, she had a biopsy of a mass in her chest in addition to

many other tests. You have gotten to know her well, spending a lot of time with

her to answer questions, explain procedures, and learn about her and her family.

You have discussed her fears about what “they” will find and know that she likes

to know everything possible about her health and clinical care. You have even

heard her express frustration with her attending physician at not always getting

the “straight story.” It is late Friday afternoon, but you promised Ms. Robbins

that you would come by one more time before the weekend and let her know if

her biopsy results were back yet. Just before you go to her room, the resident

tells you that the pathology is back from her biopsy and shows metastatic can-

cer, but the attending physician does not want the team to say anything until he

comes in on Monday.

What are you going to do? You feel that it is wrong to avoid the situation by

not going to her room. You also believe that the patient’s preference and anxiety

are best served by not waiting for 3 days. You do not want to go against the

attending physician’s clear instructions, however, because you respect the fact

that it is his patient.

In this situation, telling the patient about her biopsy results is dictated by several
ethical principles: the patient’s best interests, autonomy, and your integrity. The
other part of the ethical dilemma concerns communicating your plan to the
attending. Sometimes, the most challenging part of such dilemmas tests your will
to follow through with the right course of action. Although it may appear to be
a lose–lose situation, a respectful and honest discussion with the attending, artic-
ulating what is in the patient’s best interest, will usually be heard. Enlist the sup-
port of your resident or other helpful attendings if that is possible. Learning how
to navigate difficult discussions will be a useful professional skill.

104 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

Table 3-1 Motivational Interviewing: A Clinical Example

The police brought a 40-year-old woman to the psychiatric
emergency room because while intoxicated she threatened to
kill her partner and herself. She had no history of violence or of
legal or psychiatric problems. When she became sober the next
day, she reported calmly that she was an alcoholic and was not
violent and had no intention of hurting herself. She wanted to
be discharged. The typical psychiatric approach to this problem
would be a combination of education and confrontation; the
psychiatrist would explain the dangers of alcoholism to the pa-
tient and encourage her to seek treatment, handing her a list of
alcohol treatment centers.

In contrast, the actual motivational interviewing (MI) conver-
sation proceeded like this:

Patient: I am an alcoholic and don’t want to change. I am not
dangerous; just let me go home now.

Psychiatrist: OK, that’s what we’ll do. We can’t force you to
change. Can I just ask you a few questions and then we’ll let
you out of here?

(MI: Respect for autonomy—the psychiatrist respects the indi-
vidual’s right to change or not make a change; collaboration—
the psychiatrist is equal to the patient in power and asks
permission for further inquiry.)

Patient: OK.
Psychiatrist: I am interested in learning a little about your drinking.

I understand you don’t want to change. So I am assuming that
the alcohol is mostly a good thing in your life. I am wondering
if there is anything not so good about the alcohol in your life?

(MI: Elicit ambivalence)

Patient: Well, they said my liver is not so good anymore. It’s
going to fail if I don’t stop drinking.

Psychiatrist: OK, so that sounds like one part of the drinking that
is not so good.

(MI: Explore ambivalence)

Source: Cole S, Bogenschutz M, Hungerford M. Motivational interviewing and psychiatry: use in addiction treatment, risky drinking and routine practice. Focus
IX:42–52, 2011.

Patient: Right.
Psychiatrist: But it doesn’t sound important enough to make you

want to change. I’m guessing that you don’t care so much
whether your liver fails or not.

(MI: Not at all sarcastic here; really respecting her autonomy)

Patient: Well, I can’t live without a liver.
Psychiatrist: OK. Then it sounds like you don’t care much

whether you live or die.

(MI: Again, not at all sarcastic; simply reflecting content and
respecting autonomy)

Patient: No way! I love life!
Psychiatrist: Well, I’m not sure I understand then. On the one

hand, you are very sure that you are not going to stop drink-
ing, yet you also say you love life and don’t want your liver to
fail.

(MI: Develop discrepancy. Elicit change talk.)

Patient: Well, I know I’m going to have to cut down or stop
sometime. This is just not the time.

Psychiatrist: OK. I hear what you are saying. You want to stop
drinking at some point, to save your liver and save your life—
it’s just not the right time now.

(MI: Listen, understand, express empathy, and reflect feelings;
respect autonomy.)

Patient: Right.
Psychiatrist: OK. Can I ask another question or two?…If you do

think you’re going to stop at some point, I wonder what
thoughts you’ve had about when and how you would like to
stop drinking? Would you want or need any help if and when
you decided to cut down or stop drinking?

(MI: Open questions for understanding; encourage change
talk.)

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Interviewing and the Health History 105

Table 3-2 Brief Action Planning (BAP)—A Self-Management
Support Tool

Brief Action Planning is structured around three core questions

1. ____ Elicit person’s preferences/desires for behavior change.

“Is there anything you would like to do for your health in the next week or two?”

____ What?

____ Where?

____ When?

____ How often?

____ Elicit commitment statement

“Just to make sure we understand each other, would you please tell me back what you’ve decided to do?”

2. ____ Evaluate confidence

“I wonder how confident you feel about carrying out your plan. Considering a scale of 0 to 10, where ‘0’ means you are not at all confident
and ‘10’ means you are very confident, about how confident do you feel?”

(If the confidence level is less than 7, problem-solve how to overcome barriers or adjust the plan. “5 is great. A lot higher than zero. I
wonder if there is any way we might modify the plan to get you to a level of ‘7’ or more? Maybe we could make the goal a little easier, or you
could ask for help from a friend or family member, or even think of something else that might help you feel more confident?”

3. ____ Arrange a follow-up (or accountability).

“Sounds like a plan that’s going to work for you. When would you like to check in with me to review how you’re doing with your plan?”

Source: Steven Cole, Damara Gutnick, Connie Davis, Kathy Reims, Mary Cole BAP is a registered trademark of Steven Cole. ©2004–2012. [email protected]
com. All rights reserved. BAP may be used in clinical practice, research, and education without permission. For further information, go to www.ComprehensiveMI.
com and www.centreCMI.ca. See also Gutnick D, Reims K, et al. Brief Action Planning to facilitate behavior change and support for self-management. JCOM
2014;1:17. Available at http://www.centrecmi.ca/about-us/publications/. Accessed January 19, 2015. Originally developed circa 2004 by Steven Cole, with
contributions by Mary Cole. Current version was developed with contributions from Damara Gutnick, Connie Davis, and Kathy Reims.

106 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

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UNIT

Regional
Examinations 2

C h a p t e r 4

Beginning the Physical

Examination: General Survey,

Vital Signs, and Pain 111

C h a p t e r 5

Behavior and Mental Status 147

C h a p t e r 6

The Skin, Hair, and Nails 173

C h a p t e r 7

The Head and Neck 215

C h a p t e r 8

The Thorax and Lungs 303

C h a p t e r 9

The Cardiovascular System 343

C h a p t e r 1 0

The Breasts and Axillae 419

C h a p t e r 1 1

The Abdomen 449

C h a p t e r 1 2

The Peripheral Vascular System 509

C h a p t e r 1 3

Male Genitalia and Hernias 541

C h a p t e r 1 4

Female Genitalia 565

C h a p t e r 1 5

The Anus, Rectum, and Prostate 607

C h a p t e r 1 6

The Musculoskeletal System 625

C h a p t e r 1 7

The Nervous System 711

C H A P T E R 4 |

Beginning the Physical Examination: General Survey, Vital Signs, and Pain 111

Now that you have elicited the patient’s concerns and formed a trusting relation-
ship, you are ready to begin the physical examination. At first you may feel
unsure of your skills, but through study and repetition, the physical examination
will soon flow more smoothly, and you will shift your attention from technique
and how to handle instruments to what you hear, see, and feel (Fig. 4-1). Touch-
ing the patient’s body will seem more natural, and you will learn to minimize any
discomfort to the patient (Fig. 4-2). As you gain proficiency, what once took
between 1 and 2 hours will take considerably less time.

This chapter introduces the sections of the regional examination chapters you
will find throughout the book: The Health History of Common and Concerning
Symptoms (in this chapter, these are common constitutional symptoms); Health
Promotion and Counseling, which focuses in this chapter on lifestyle components
such as weight, nutrition, and exercise; then, Techniques of Examination, which
include the initial elements of the physical examination, the General Survey, Vital
Signs, and assessment of pain; followed by Tables and the References. The regional
examination chapters, Chapters 6 through 20, begin with an additional section,
Anatomy and Physiology.

C H A P T E R

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

The Bates’ suite offers these additional resources to enhance learning and facilitate
understanding of this chapter:
■ Bates’ Pocket Guide to Physical Examination and History Taking, 8th edition
■ Bates’ Visual Guide to Physical Examination (Vol. 5: General Survey and Vital Signs)
â–  thePoint online resources, for students and instructors: http://thepoint.lww.com

F I G U R E 4 – 1 . The physical

examination flows more efficiently

with practice.

F I G U R E 4 – 2 . The clinician’s touch

can reassure as well as assess.

112 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE HEALTH HISTORY

Common or Concerning Symptoms

● Fatigue and weakness
● Fever, chills, night sweats
● Weight change
● Pain

Fatigue and Weakness. Fatigue is a nonspecific symptom with many
causes. It refers to a sense of weariness or loss of energy that patients describe in
various ways. “I don’t feel like getting up in the morning” . . . “I don’t have any
energy” . . . “I can hardly get through the day” . . . “By the time I get to work, I feel
as if I’ve done a day’s work.” Because fatigue is a normal response to hard work,
sustained stress, or grief, elicit the life circumstances in which it occurs. Fatigue
unrelated to such situations requires further investigation.

Use open-ended questions to encourage the patient to fully describe what he or
she is experiencing. Important clues about etiology often emerge from a good
psychosocial history, exploration of sleep patterns, and a thorough review of
systems.

Weakness is different from fatigue. It denotes a demonstrable loss of muscle
power and will be discussed later with other neurologic symptoms (see
p. 723).

Fever, Chills, and Night Sweats. Fever refers to an abnormal
elevation in body temperature (see p. 133 for definitions of normal). Ask
about fever if the patient has an acute or chronic illness. Find out if the patient
has measured his or her temperature. Has the patient felt feverish or unusually
hot, noted excessive sweating, or felt chilly and cold? Try to distinguish
between feeling cold, and a shaking chill with shivering throughout the body
and chattering of teeth.

Feeling cold, goosebumps, and shivering accompany a rising temperature,
whereas feeling hot and sweating accompanies a falling temperature. Normally,
the body temperature rises during the day and falls during the night. When fever
exaggerates this swing, night sweats occur. Malaise, headache, and pain in the
muscles and joints often accompany fever.

Fever has many causes. Focus on the timing of the illness and its associated
symptoms. Become familiar with patterns of infectious diseases that may
affect your patient. Inquire about travel, contact with sick people, or other
unusual exposures. Even medications may cause fever. By contrast, recent
ingestion of aspirin, acetaminophen, corticosteroids, and nonsteroidal anti-
inflammatory drugs may mask fever and affect the temperature recorded at
the office visit.

Fatigue is a common symptom of

depression and anxiety, but also con-

sider infections (such as hepatitis,
infectious mononucleosis, and tuber-

culosis); endocrine disorders (hypothy-
roidism, adrenal insufficiency,

diabetes mellitus); heart failure;

chronic disease of the lungs, kidneys,

or liver; electrolyte imbalance; moder-

ate to severe anemia; malignancies;

nutritional deficits; and medications.

Weakness, especially if localized in a

neuroanatomical pattern, suggests

possible neuropathy or myopathy.

Recurrent shaking chills suggest more

extreme swings in temperature and

systemic bacteremia.

Feeling hot and sweating also accom-

pany menopause. Night sweats occur

in tuberculosis and malignancy.

In immunocompromised patients

with sepsis, fever may be absent,

low-grade, or drop below normal

(hypothermia).

E X A M P L E S O F A B N O R M A L I T I E S

The Health History

C H A P T E R 4 |

Beginning the Physical Examination: General Survey, Vital Signs, and Pain 113

THE HEALTH HISTORY

Weight Change. Weight change results from changes in body tissues or
body fluid. Good opening questions include “How often do you check your
weight?” “How is it compared to a year ago?” If there are changes, ask, “Why do
you think it has changed?” “What would you like to weigh?” If weight gain or
loss appears to be a problem, ask about the amount of change, its timing, the
setting in which it occurred, and any associated symptoms.

Weight gain occurs when caloric intake exceeds caloric expenditure over time,
and typically results in increased body fat. Weight gain can also reflect abnormal
accumulation of body fluids, particularly when the gain is very rapid.

Patients with a body mass index (BMI) of ≥25 to 29 are defined as overweight;
those with a BMI ≥30 are considered obese. For these patients, plan a thorough
assessment to avert the many associated risks of morbidity and mortality. Clarify
the timing and evolution of the weight gain. Was the patient overweight as a
child? Are the parents overweight? Ask about weight at life milestones like birth,
kindergarten, high school or college graduation, military discharge, pregnancy,
menopause, and retirement. Has a recent disability or surgery affected weight?
What about depression or anxiety? Is there a change in sleep pattern or daytime
drowsiness suspicious for sleep apnea?1 Establish the level of physical activity
and results of prior attempts at weight loss. Assess eating patterns and dietary
preferences.

Review the patient’s medications.

Explore any clinically significant weight loss, defined as loss of 5% or more of
usual body weight over a 6-month period. Mechanisms include decreased food
intake due to anorexia, depression, dysphagia, vomiting, abdominal pain, or
financial difficulties; defective gastrointestinal absorption or inflammation; and
increased metabolic requirements. Ask about abuse of alcohol, cocaine, amphet-
amines, or opiates, or withdrawal from marijuana, all associated with weight
loss. Heavy smoking also suppresses appetite.

Assess food intake. Has it been normal, dropped, or even increased?

Rapid changes in weight, over a few

days, suggest changes in body fluid,

not tissue.

Edema from extravascular fluid

retention is visible in heart failure,
nephrotic syndrome, liver failure,
and venous stasis.

See Classification of Overweight and

Obesity by BMI on p. 116.

See Table 4-1, Obesity-Related Health

Conditions, p. 139, and discussion on

pp. 114–118.

Many drugs are associated with

weight gain, such as: tricyclic antide-

pressants; insulin and sulfonylurea;

contraceptives, glucocorticoids, and

progestational steroids; mirtazapine

and paroxetine; gabapentin and

valproate; and propranolol.

Causes of weight loss include gas-

trointestinal diseases; endocrine

disorders (diabetes mellitus, hyper-
thyroidism, adrenal insufficiency);
chronic infections, HIV/AIDS; malig-

nancy; chronic cardiac, pulmonary,

or renal failure; depression; and

anorexia nervosa or bulimia.

See Table 4-2, Eating Disorders and

Excessively Low BMI, p. 140.

Weight loss with relatively high food

intake suggests diabetes mellitus,
hyperthyroidism, or malabsorption.
Consider also binge eating (bulimia)
with clandestine vomiting.

E X A M P L E S O F A B N O R M A L I T I E S

114 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

HEALTH PROMOTION AND COUNSELING

Pursue a thorough psychosocial history. Who cooks and shops for the patient?
Where does the patient eat? With whom? Are there any problems with obtaining,
storing, preparing, or chewing food? Does the patient avoid or restrict certain
foods for medical, religious, or other reasons?

Check the medication history.

Be alert for symptoms and signs of malnutrition. These may be subtle and non-
specific, such as weakness, easy fatigability, cold intolerance, flaky dermatitis,
and ankle swelling. Securing a good diet history of eating patterns and quantities
is essential. Ask general questions about intake at different times throughout the
day, such as “Tell me what you typically eat for lunch.” “What do you eat for a
snack?” “When?”

Pain. Pain is one of the most common presenting symptoms in office
practice. Each year, an estimated 100 million Americans experience chronic
pain at a cost in medical care, disability, and work days lost of $560 to $635
million.3,4 Acute pain affects another 12% of Americans annually.5 The most
frequent causes are low back pain, headache or migraine, and knee and neck
pain; prevalence varies by race, ethnicity, and socioeconomic status.
Localizing symptoms, “the seven attributes of every symptom,” and the
psychosocial history are essential to your physical examination, assessment,
and a comprehensive management plan.

Poverty, old age, social isolation,

physical disability, emotional or men-

tal impairment, lack of teeth, ill-fitting

dentures, alcoholism, and drug abuse

increase risk of malnutrition.

Drugs associated with weight loss

include anticonvulsants, antidepres-

sants, levodopa, digoxin, metformin,

and thyroid medication.2

See Table 4-3, Nutrition Screening,

p. 141.

Turn to the section on Acute and

Chronic Pain, pp. 134–137, at the end

of this chapter for an approach to

assessment and management.

Important Topics for Health Promotion
and Counseling

● Optimal weight, nutrition, and diet
● Blood pressure and dietary sodium
● Exercise

Optimal Weight, Nutrition, and Diet. Fewer than half of U.S. adults
maintain a healthy weight, defined as a BMI between 18.5 and 24.9 kg/m2.
Obesity has increased in every segment of the U.S. population, regardless of age,
gender, ethnicity, geographic area, or socioeconomic status. Review the alarming
statistics about the epidemic of obesity nationally and worldwide in the table on
the next page.6–8

See Calculating the BMI and Measuring

the Waist Circumference, pp. 122–123.

E X A M P L E S O F A B N O R M A L I T I E S

Health Promotion and
Counseling: Evidence and
Recommendations

C H A P T E R 4 |

Beginning the Physical Examination: General Survey, Vital Signs, and Pain 115

HEALTH PROMOTION AND COUNSELING

To promote optimal patient weight and nutrition, adopt the four-pronged
approach outlined here. Reducing weight by even 5% to 10% can improve blood
pressure, lipid levels, and glucose tolerance, and reduce the risk of diabetes or
hypertension.

Obesity at a Glance

● Nearly 69% of U.S. adults are overweight or obese (BMI ≥25 kg/m2), including
71% of men, 66% of women; overall, about 35% of U.S. adults are obese.

● About 15% of U.S. children and adolescents are overweight and 17% are obese.
● Health disparities: the prevalence of overweight or obesity varies by racial/

ethnic and socioeconomic groups:
● Women: black women, 82%; Hispanic women, 77%; non-Hispanic white

women, 63%.
● Higher-income women are less likely to be obese than low-income women.
● Men: Hispanic men, 79%; non-Hispanic white men, 71%; black men, 69%.
● Youth ages 2 to 19 years: highest prevalence in Hispanic boys and girls

(41%; 37%), black boys and girls (34%; 36%), children living in low-income,

low-education, and higher-unemployment households.
● Overweight and obesity increase risk of heart disease, numerous types of

cancers, type 2 diabetes, stroke, arthritis, sleep apnea, infertility, and depres-

sion. Obesity may increase risk of death.9,10

● More than 80% of people with type 2 diabetes and over 20% of people with

hypertension are overweight or obese.
● Obesity is increasing worldwide, affecting an estimated 2.1 billion overweight

and obese individuals.11 The prevalence of overweight and obesity is higher in

developed countries at all ages. In the world’s poorest countries, poverty is

associated with underweight and malnutrition; but poverty in a middle-

income country adopting a Western lifestyle increases the risk of obesity.
● Only 65% of obese U.S. adults report that health care professionals have told

them that they were overweight. Less than half report being advised by a

health care professional to lose weight, though obese adults with diabetes are

more likely to receive such advice.12

Sources: Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics–2014 update: a

report from the American Heart Association. Circulation. 2014;129(3):e28; Ogden CL, Carroll MD,
Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA.
2014;311(8):806; Ogden CL, Carroll MD, Kit BK, et al. Prevalence of obesity among adults: United

States, 2011–2012. NCHS Data Brief. 2013;(131):1; Centers for Disease Control and Prevention. Obesity
and overweight. Data and statistics. Available at http://www.cdc.gov/obesity/data/index.html.

Accessed December 1, 2014.

See Table 4-1, Obesity-Related Health

Conditions, p. 139.

Four Steps to Promote Optimal Weight
and Nutrition

1. Measure BMI and waist circumference; adults with a BMI ≥25 kg/m2, men
with waist circumferences >40 inches, and women with waist circumfer-
ences >35 inches are at increased risk for heart disease and obesity-related
diseases. Measuring the waist-to-hip ratio (waist circumference divided by

E X A M P L E S O F A B N O R M A L I T I E S

(continued )

116 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

HEALTH PROMOTION AND COUNSELING

Take advantage of the excellent resources available for patient assessment and
counseling summarized in the following sections.13 Review the role of weight
in the growing prevalence of metabolic syndrome, present in about 34% of the
U.S. population.6

Step 1: Measure the BMI and Assess Risk Factors. Classify the BMI
according to the national guidelines in the following table. If the BMI is above
25 kg/m2, assess the patient for additional risk factors for heart disease and other
obesity-related diseases: hypertension, high low-density lipoprotein (LDL) cho-
lesterol, low high-density lipoprotein (HDL) cholesterol, high triglycerides, high
blood glucose, family history of premature heart disease, physical inactivity, and
cigarette smoking. Patients with a BMI over 25 kg/m2 and two or more risk fac-
tors should pursue weight loss—especially if the waist circumference is elevated.

See definition and discussion of

metabolic syndrome in Chapter 9,
Cardiovascular System, p. 370.

Classification of Overweight and Obesity by BMI

Obesity Class BMI (kg/m2)

Underweight <18.5
Normal 18.5–24.9

Overweight 25.0–29.9

Obesity I 30.0–34.9

II 35.0–39.9

Extreme obesity III ≥40

Source: National Institutes of Health and National Heart, Lung, and Blood Institute: Clinical

Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults:

The Evidence Report. NIH Publication 98–4083. June 1998. Available at http://www.nhlbi.nih.gov/

guidelines/obesity/ob_gdlns.pdf. Accessed January 21, 2015.

Step 2: Assess Dietary Intake. Take a diet history and assess the patient’s
eating patterns. Select a brief screening tool and be sensitive to the impact of
income and cultural preferences on what the patient chooses to eat.

Step 3: Assess Motivation to Change. Once you have assessed BMI,
risk factors, and dietary intake, address the patient’s motivation to make lifestyle
changes that promote weight loss. The Prochaska model helps tailor interven-
tions to the patient’s level of motivation to adopt new eating behaviors.

See Table 4-3, Nutrition Screening,

p. 141.

See Table 4-4, Obesity: Stages of

Change Model and Assessing

Readiness, p. 142.

E X A M P L E S O F A B N O R M A L I T I E S

Four Steps to Promote Optimal Weight
and Nutrition (continued )

hip circumference) may be a better risk predictor for individuals older than

75 years. Ratios >0.95 in men and >0.85 in women are considered elevated.
Determine additional risk factors for cardiovascular diseases, including smok-

ing, high blood pressure, high cholesterol, physical inactivity, and family history.

2. Assess dietary intake.
3. Assess the patient’s motivation to change.
4. Provide counseling about nutrition and exercise.

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HEALTH PROMOTION AND COUNSELING

Step 4: Provide Counseling About Nutrition and Exercise. You
should be well informed about diet and nutrition as you counsel overweight
patients, especially in light of the many and often contradictory diet options in
the popular press. The U.S. Department of Agriculture released new dietary
guidelines in 2010 to help clinicians and patients address the obesity epidemic
more effectively.14 The Department’s new nutrition icon, MyPlate, is appealing
and easy to understand (Fig. 4-3). Review the MyPlate website and the dietary
guidelines report, as well as recent guides for identifying and managing over-
weight and obesity from the National Heart, Lung, and Blood Institute and the
Agency for Healthcare Research and Quality.10,15

A key element of effective counseling is working with the patient to set reason-
able goals. Experts note that patients often have a “dream weight” as much as
30% below initial body weight.2 However, a 5% to 10% weight loss is more
realistic and still proven to reduce risk of diabetes and other obesity-associated
health problems. Educate your patients about common roadblocks to sus-
tained weight loss: hitting a plateau due to feedback physiologic systems that
maintain body homeostasis; poor adherence to diet due to increasing hunger
over time as weight declines; and inhibition of leptin, a protein cytokine
secreted and stored in fat cells that modulates hunger.16 Use a full array of
strategies to promote weight loss. A safe goal for weight loss is 0.5 to 2 lbs
per week.

F I G U R E 4 – 3 . The MyPlate icon

helps patients understand nutrition.

(U.S. Department of Agriculture.)

Strategies That Promote Weight Loss

● The most effective diets combine realistic weight loss goals with exercise and

behavioral reinforcements.
● Encourage patients to walk 30 to 60 minutes 5 or more days a week, or a total

of at least 150 minutes a week. Pedometers help patients match distance in

steps with calories burned.
● The total calorie deficit goal, usually 500 to 1,000 kilocalories a day, is more

important than the type of diet. Since many types of diets have been studied

and appear to confer similar results, support the patient’s preferences as long

as they are reasonable.17,18 Consider low-fat diets for those with dyslipidemias.
● Encourage proven behavioral habits such as portion-controlled meals, meal

planning, food diaries, and activity records.
● Follow professional guidelines for pharmacologic therapies in patients having

high weights and morbidities who do not respond to conventional treatment.19

If the BMI falls below 18.5 kg/m2, investigate possible anorexia, bulimia, or other
serious medical conditions.

The USDA Dietary Guidelines 2010 point out that to maintain caloric balance and
achieve and sustain a healthy weight, most Americans need to lower their caloric
intake and increase physical activity. The Guidelines emphasize consuming nutrient-
dense foods and beverages such as vegetables, fruits, whole grains, fat-free or low-fat

See Table 4-2, Eating Disorders and

Excessively Low BMI, p. 140.

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118 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

HEALTH PROMOTION AND COUNSELING

milk and milk products, seafood, lean meats and poultry, eggs, beans and peas, and
nuts and seeds.14 Intake of added sugars (primarily sweeteners), solid saturated and/
or trans fats, and refined grains make it difficult to achieve optimal nutrition.

Introduce your patients to the colorful “chooseMyPlate.gov” website and its easy-
to-follow guides for selecting fruits, vegetables, grains, protein, and dairy prod-
ucts. Sodium intake should be less than 2,300 mg/day, saturated fatty acids
should be ≤10% of total calories, and dietary cholesterol should be ≤300 mg/day.
Encourage patients to follow simple practical tips for daily meals, the “10 Tips to
a Great Plate” listed below.

10 Tips to a Great Plate

1. Balance calories.
2. Eat less.
3. Avoid oversized portions.
4. Eat nutrient-dense foods more often.
5. Make half the plate fruits and vegetables.
6. Switch to fat-free or low-fat milk.
7. Make half of grain intake whole grains.
8. Eat foods high in solid fats, salt, and added sugars less often.
9. Use the Nutrition Facts label to choose lower sodium versions of foods like

soup, bread, and frozen meals.

10. Drink water or unsweetened beverages instead of sweetened soda, energy
drinks, or sports drinks.

Source: Choose My Plate–10 Tips to a Great Plate. Available at www.choosemyplate.gov/food-

groups/downloads/TenTips/DGTipsheet1ChooseMyPlate.pdf. Accessed January 21, 2015. U.S.

Department of Agriculture.

Help adolescent females and women of childbearing age increase intake of iron,
vitamin C, and folic acid. Assist adults older than 50 years to identify foods rich
in vitamin B12. Advise older adults and those with dark skin or low exposure to
sunlight to increase intake of vitamin D.

Blood Pressure and Dietary Sodium. Excess sodium intake can lead
to hypertension, a major risk factor for cardiovascular disease. A meta-analysis
concludes that a difference of 5 g of salt intake a day is linked to a 23% difference
in the rate of stroke and a 17% difference in the rate of total cardiovascular
disease.20 The Institute of Medicine (IOM) has determined that a daily dietary
intake of 2,300 mg of sodium is the tolerable upper intake level for adults.21
However, the average sodium intake among Americans is 3,400 mg/day and over
90% of adults exceed the recommended upper intake level.22 While reducing
sodium intake to 1,500 mg provides better blood pressure control, the IOM
found no evidence of benefit for overall health outcomes below the 2,300 mg
level.21 Even without achieving this level, reducing sodium intake by at least
1,000 mg/day lowers blood pressure.23

Because over 75% of consumed sodium comes from processed foods and less than
10% of Americans consume 2,300 mg/day or less of recommended dietary sodium, the

See Table 4-5, Nutrition Counseling:

Sources of Nutrients, p. 143.

See Table 4-6, Patients with Hyper-

tension: Recommended Changes in

Diet, p. 143.

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American Heart Association and the IOM have jointly recommended population-
wide salt reduction measures including government standards for manufacturers,
restaurants, and foodservice operators.24,25 Advise patients to read the Nutrition
Facts panel on food labels closely to help them adhere to the 2,300-mg/day guide-
line. Urge them to consider the well-investigated Dietary Approaches to Stop
Hypertension, or DASH Eating Plan, for a model diet.26

Exercise. Physical fitness is a key component of both weight control and weight
loss. To achieve health benefits, adults should do at least 150 minutes (2 hours and
30 minutes) of moderate-intensity cardiorespiratory activity, for example, walking
briskly at a pace of 3 to 4.5 miles (4.8 to 7.2 km) per hour, each week.27,28 Patients
can increase exercise by such simple measures as parking farther away from their
place of work or using stairs instead of elevators. Alternatively, adults can engage
in vigorous-intensity aerobic activity, such as jogging or running, for 75 minutes
(1 hour and 15 minutes) each week. An equivalent combination of moderate- and
vigorous-intensity aerobic activity is also beneficial. Greater health benefits can be
achieved by increasing the frequency, duration, and/or intensity of physical activity.

Moderate and Vigorous Exercise

A 154-lb (69 kg) man who is 5′10″ uses up approximately the number of calories
listed doing each activity below. Those who weigh more will use more calories, and
those who weigh less will use fewer. The calorie values listed include both calories
used by the activity and calories used for normal body functioning.

Approximate Calories Used
by a 154-lb Man

In 1 hour In 30 minutes

Moderate Physical Activities:
Hiking

Light gardening/yard work

Dancing

Golf (walking and carrying clubs)

Bicycling (less than 10 miles per hour)

Walking (3.5 miles per hour)

Weight training (general light workout)

Stretching

370

330

330

330

290

280

220

180

185

165

165

165

145

140

110

90

Vigorous Physical Activities:
Running/jogging (5 miles per hour)

Bicycling (more than 10 miles per hour)

Swimming (slow freestyle laps)

Aerobics

Walking (4.5 miles per hour)

Heavy yard work (chopping wood)

Weight lifting (vigorous effort)

Basketball (vigorous)

590

590

510

480

460

440

440

440

295

295

255

240

230

220

220

220

Source: U.S. Department of Agriculture: Choose MyPlate.gov. Physical Activity. How many calories

does physical activity use? Modified June 2011. Available at http://www.choosemyplate.gov/food-

groups/physicalactivity_calories_used_table.html. Accessed January 21, 2015.

120 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE GENERAL SURVEY

The General Survey of the patient’s appearance, height, and weight begins with the
opening moments of the patient encounter, but your observations of the patient’s
appearance often crystallize as you start the physical examination. The best clini-
cians continually sharpen their powers of observation and description. As you
talk with and examine the patient, heighten your focus on the patient’s mood,
build, and behavior. These details enrich and deepen your emerging clinical
impression. Your goal is to describe the distinguishing features of the patient so
clearly that colleagues can spot the patient in a crowd of strangers, avoiding cli-
chés like “middle-aged gentleman” and the uninformative “in no acute distress.”

Many factors contribute to the patient’s body habitus: socioeconomic status,
nutrition, genetic makeup, physical fitness, mood state, early illnesses, gender,
geographic location, and age cohort. Nutritional status affects many of the char-
acteristics you scrutinize during the General Survey: height and weight, blood
pressure, posture, mood and alertness, facial coloration, dentition and condition
of the tongue and gingiva, color of the nail beds, and muscle bulk, to name a few.
Your assessment of height, weight, BMI, and risk for obesity should be routine
for each patient in your clinical practice.

Recall your observations from the first moments of the encounter that you have
been refining throughout your assessment. Does the patient hear you when
greeted in the waiting room or examination room? Rise with ease? Walk easily or
stiffly? If hospitalized when you first meet, what is the patient doing—sitting up
and enjoying television? . . . or lying in bed? . . . What do you see on the bedside
table—a magazine? . . . candy bars or chips? . . . a Bible or a rosary? . . . multiple
beverage containers? . . . or nothing at all? Each observation raises questions or
hypotheses to consider as your assessment unfolds.

General Appearance

Apparent State of Health. Try to make a general judgment based on
observations throughout the encounter. Support it with the significant details.

Level of Consciousness. Is the patient awake, alert, and responsive to
you and others in the environment? If not, promptly assess the level of
consciousness.

Signs of Distress. Does the patient show evidence of the problems listed
below?

â–  Cardiac or respiratory distress

â–  Pain

Is the patient acutely or chronically ill,

frail, or fit and robust?

See Chapter 17, The Nervous System,

Level of Consciousness, pp. 768–769.

Is there clutching of the chest, pallor,

diaphoresis, labored breathing,

wheezing, or coughing?

Is there wincing, diaphoresis, protec-

tiveness of a painful area, grimacing,

or an unusual posture favoring one

limb or region of the body?

E X A M P L E S O F A B N O R M A L I T I E S

The General Survey

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â–  Anxiety or depression

Skin Color and Obvious Lesions. Inspect for any changes in skin color,
scars, plaques, or nevi.

Dress, Grooming, and Personal Hygiene. How is the patient
dressed? Is the clothing suitable for the temperature and weather? Is it clean and
appropriate to the setting?

Notice the patient’s shoes. Are there cut-outs or holes? Are the shoes run-down?

Is the patient wearing unusual jewelry? Are there body piercings?

Note the patient’s hair, fingernails, and use of make-up. They may be clues to the
patient’s personality, mood, lifestyle, and self-regard.

Do personal hygiene and grooming seem appropriate for the patient’s age, life-
style, and occupation?

Facial Expression. Observe the facial expression at rest, during
conversation and social interactions, and during the physical examination.
Watch closely for eye contact. Is it natural? . . . sustained and unblinking? . . . averted
quickly? . . . absent?

Odors of the Body and Breath. Odors can be important diagnostic
clues, like the fruity odor of diabetes or the scent of alcohol.

Are there anxious facial expressions,

fidgety movements, cold moist palms,

inexpressive or flat affect, poor eye

contact, or psychomotor slowing?

See Chapter 5, Behavior and Mental

Status, pp. 147–171.

Pallor, cyanosis, jaundice, rashes,

bruises, or mottling of the extremities

should be pursued. See Chapter 6, The

Skin, Hair, and Nails, pp. 173–214.

Excess clothing may reflect the cold

intolerance of hypothyroidism, hide
skin rash or needle marks, mask

anorexia, or signal personal lifestyle

preferences.

Holes or slippers suggest gout,

bunions, edema, or other painful foot

conditions. Run-down shoes can

contribute to foot and back pain,

calluses, falls, and infection.

Copper bracelets suggest joint pain.

Tattoos and piercings can be associ-

ated with alcohol and drug use.29

“Grown-out” hair and nail polish

suggest the length of a possible

illness. Bitten fingernails may

reflect stress.

Neglected appearance may appear

in depression and dementia, but
should be compared with the

patient’s norm.

Watch for the stare of hyperthyroidism,
the immobile facies of parkinsonism,
and the flat or sad affect of depression.
Decreased eye contact may be

cultural or suggest anxiety, fear, or

sadness.

Breath odors can reveal the presence

of alcohol or acetone (diabetes),

pulmonary infections, uremia, or

liver failure.

E X A M P L E S O F A B N O R M A L I T I E S

122 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE GENERAL SURVEY

Never assume that alcohol on a patient’s breath explains changes in mental status
or neurologic findings.

Posture, Gait, and Motor Activity. What is the patient’s preferred
posture?

Is the patient restless or quiet? How often does the patient change position?

Is there any involuntary motor activity? Are some body parts immobile? Which
ones?

Does the patient walk smoothly, with comfort, self-confidence, and balance, or
is there a limp, fear of falling, loss of balance, or any movement disorder?

Height and Weight. Measure the patient’s height and weight with shoes
removed to determine the BMI. Note any changes in height or weight over time.

Is the patient unusually short or tall? Is the build slender, muscular, or stocky?
Is the body symmetric? Note the general body proportions.

Is the patient emaciated, slender, overweight, or obese? If the patient is obese, is
the fat distributed evenly, concentrated over the upper torso, or settled around
the hips?

Make note of any weight changes.

Calculating the BMI. Use your measurements of height and weight to
determine BMI. Body fat consists primarily of adipose in the form of triglycerides
and is stored in subcutaneous, intra-abdominal, and intramuscular fat deposits
that are difficult to measure directly. The BMI incorporates estimated but more
accurate measures of body fat than weight alone. The National Institutes of

These changes can have serious but

treatable causes such as hypoglyce-

mia, subdural hematoma, or postictal

state.

Patients often prefer sitting upright in

left-sided heart failure and leaning
forward with arms braced in chronic
obstructive pulmonary disease.

Anxious patients appear agitated and

restless. Patients in pain often avoid

movement.

Look for tremors, other involuntary

movements, or paralysis. See Table 17-5,

Tremors and Involuntary Movements,

pp. 782–783.

See Table 17-10, Abnormalities of Gait

and Posture, p. 789. An impaired gait

increases risk of falls.

Watch for very short stature in Turner
syndrome, childhood renal failure, and
achondroplastic and hypopituitary
dwarfism; long limbs in proportion to
the trunk in hypogonadism and

Marfan syndrome; and height loss in
osteoporosis and vertebral compres-
sion fractures.

There is generalized fat distribution in

simple obesity and truncal fat with

relatively thin limbs in Cushing syn-
drome and metabolic syndrome.

Causes of weight loss include malig-

nancy, diabetes mellitus, hyperthyroid-
ism, chronic infection, depression,
diuresis, and successful dieting.

See discussion of Optimal Weight,

Nutrition, and Diet, pp. 114–118.

E X A M P L E S O F A B N O R M A L I T I E S

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Health caution that people who are very muscular can have a high BMI, but still
be healthy. Likewise, the BMI for older adults and those with low muscle mass
may appear inappropriately “normal.”

To determine the BMI, choose the method best suited to your practice. Use a
standard BMI table or the electronic medical record software, which frequently
shows the BMI automatically.30 You can also calculate the BMI using one of the
methods shown below.

Methods to Calculate Body Mass Index (BMI)

Unit of Measure Method of Calculation

Weight in pounds, height in inches (1) Standard BMI Chart

(2)

Weight (lbs) × 700*
Height (inches)

Weight in kilograms, height in
meters squared

(3)

Weight (kg)

Height (m )2

Either unit of measure (4) “BMI Calculator” at http://www.
nhlbi.nih.gov/health/educational/

lose_wt/BMI/bmicalc.htm

*Several organizations use 704.5, but the variation in BMI is negligible. Conversion formulas: 2.2 lb =
1 kg; 1 inch = 2.54 cm; 100 cm = 1 m.
Source: National Institutes of Health–National Heart, Lung, and Blood Institute: Calculate Your

Body Mass Index. Available at: http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.

htm. Accessed January 21, 2015.

Waist Circumference. If the BMI is ≥35 kg/m2, measure the patient’s
waist circumference just above the hips. Risk for diabetes, hypertension, and
cardiovascular disease increases significantly if the waist circumference is
35 inches or more in women and 40 inches or more in men.

See Table 9-3, Abnormalities of the

Arterial Pulse and Pressure Waves,

p. 402.

E X A M P L E S O F A B N O R M A L I T I E S

The Vital Signs
The Vital Signs—blood pressure, heart rate, respiratory rate, and temperature—
provide critical initial information that often influences the tempo and direction
of your evaluation. If already recorded by office staff, review the Vital Signs
promptly at the outset of the encounter. If the Vital Signs are abnormal, you will
often retake them yourself during the visit.

Begin by measuring the blood pressure and the heart rate. Count the heart rate
for one minute by palpating the radial pulse with your fingers, or by listening for
the apical pulse with your stethoscope at the cardiac apex. Continue either of
these techniques as you quietly count the respiratory rate, since once patients are

124 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE VITAL SIGNS

alerted, their breathing patterns may change. The temperature may be taken in
various sites, depending on the patient and the equipment available. Learn the
techniques that ensure accuracy when you measure the vital signs, described in
the pages to follow.

Blood Pressure

The Complexities of Measuring Blood Pressure. The accuracy of
blood pressure measurements varies according to how these measurements are
taken. Office screening with manual and automated cuffs remains common, but
elevated readings increasingly require confirmation with home and ambulatory
monitoring. In its 2014 draft recommendations, the U.S. Preventive Services
Task Force reported that 5% to 65% of elevated office blood pressures failed to
be confirmed by ambulatory monitoring and recommended ambulatory blood
pressure monitoring to confirm the diagnosis of hypertension.31 Numerous
studies show that ambulatory and home blood pressure monitoring are more
predictive of cardiovascular disease and end organ damage than manual and
automated measurements in the office.32 Automated ambulatory blood pressure
monitoring measures blood pressure at preset intervals over 24 to 48 hours,
usually every 15 to 20 minutes during the day and 30 to 60 minutes during the
night. It is now considered the reference standard for confirming elevated office
blood pressures.33

Be familiar with the important features of the different methods for measuring
blood pressure, summarized in the table below, since errors in office readings
raise substantial risks of misdiagnosis and unnecessary treatment.

F I G U R E 4 – 4 . Auscultatory blood

pressure measurement with arm at

heart level.

Methods for Measuring Blood Pressure

Method Features

Auscultatory office blood

pressure with aneroid or

mercury blood pressure

cuff (Fig. 4-4)

Common, inexpensive

Subject to patient anxiety (“white coat hyper-

tension”), observer technique, cuff recalibra-

tion every 6 months

Requires measurements over several visits

Ambulatory or home monitoring needed to

detect masked hypertension

Single measurements with sensitivity and

specificity of 75% compared to ambulatory

monitoring34

Automated oscillometric

office blood pressure

Requires optimal patient positioning, cuff size

and placement, and device calibration

Takes multiple measurements over short period

Requires confirmatory measurements to reduce

misdiagnosis

Comparable sensitivity and specificity to manual

measurements34

(continued )

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If you recommend home blood pressure monitoring, advise patients about how
to choose the best upper arm cuff for home use and have it recalibrated. Let them
know that wrist and fingers monitors are popular but less accurate. Systolic pres-
sure increases in more distal arteries, whereas diastolic pressure falls; and hydro-
static effects introduce errors due to differences in position relative to the heart.

Definitions for Diagnosing Hypertension. Note the differences in
the definitions of hypertension depending on the measurement method used.

Patient education about the correct

use of home monitors is essential.

Make sure patients understand all

the steps needed to ensure accurate

readings at home, as detailed in this

section.

Definitions of Hypertension

● Office manual or automated blood pressure based on the average of two

readings on two separate occasions: ≥140/9035,36
● Home automated blood pressure: <135/8532
● Ambulatory automated blood pressure:37

● 24-hour average: ≥ of 130/80
● Daytime (awake) average: ≥135/85
● Nighttime (asleep) average: >120/70

Methods for Measuring Blood Pressure (continued )

Method Features

Home blood pressure

monitoring

Accurate automated device applied by patient,

easy to use, less expensive than ambulatory

monitoring

Acceptable alternative if ambulatory monitor-

ing not feasible; more predictive of cardio-

vascular risk than office measurements32

Requires patient education for accurate tech-

nique, repeated measurements (two morn-

ing, two evening readings daily for 1 week);

nighttime readings not recorded32

Detects white coat hypertension—present in 20%32

Detects masked hypertension—present in 10%
(blood pressure is higher than office readings)32

Sensitivity 85%, specificity 62% compared to

ambulatory monitoring34

Ambulatory blood pressure

monitoring

Automated; clinical and research “gold standard”

Provides 24-hour average blood pressures and

averages of daytime (awake), nighttime

(asleep), systolic, and diastolic blood pressures

Shows whether nocturnal blood pressure “dips”

(normal) or stays elevated ( = cardiovascular
disease risk factor)

More expensive; may not be covered by insurance

126 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE VITAL SIGNS

Types of Hypertension. Three types of hypertension are especially
important to recognize: white coat hypertension, masked hypertension, and nocturnal
hypertension. Suspicion of these entities and assessing the effects of treatment are
indications for ambulatory blood pressure monitoring.

â–  White coat hypertension (isolated clinic hypertension): White coat hyper-
tension is defined as blood pressure ≥140/90 in medical settings and mean
awake ambulatory readings <135/85. This phenomenon, reported in up to
20% of patients with elevated office blood pressure, is important to identify
since it carries normal to slightly increased cardiovascular risk and does not
require treatment.32,37 It is attributed to a conditioned anxiety response. Poor
measurement technique, including rounding of measurements to zero, the
presence of a physician or nurse, and even the prior diagnosis of hyperten-
sion can also substantially alter office readings. Replacing manual office mea-
surements with an automated device that makes several readings with the
patient seated alone in a quiet room has been shown to reduce the “white
coat effect.”38

â–  Masked hypertension: Masked hypertension, defined as office blood pres-
sure <140/90, but an elevated daytime blood pressure of >135/85 on
home or ambulatory testing, is more serious. Untreated adults with
masked hypertension, an estimated 10% to 30% of the general popula-
tion, have increased risk of cardiovascular disease and end-organ
damage.32,37

■ Nocturnal hypertension: Physiologic blood pressure “dipping” occurs in
most patients at night as they shift from wakefulness to sleep. A nocturnal
fall of <10% of daytime values is associated with poor cardiovascular out-
comes and can only be identified on 24-hour ambulatory blood pressure
monitoring. Two other patterns have poor cardiovascular outcomes, a
nocturnal rising pattern and a marked nocturnal fall of >20% of daytime
values.37

Choosing the Correct Blood Pressure Cuff (Sphygmoma-
nometer). More than 76 million Americans have elevated blood pressure.39
To detect blood pressure elevations, an accurate instrument is essential. Four
types of office blood pressure devices are currently used: mercury, aneroid,
electronic, and “hybrid,” which combines features of both electronic and
ambulatory devices. In hybrid devices, the mercury column is replaced by an
electronic pressure gauge; blood pressure can be displayed as a simulated
mercury column, an aneroid reading, or a digital readout. All measuring
instruments should be routinely tested for accuracy using international
protocols.40,41

Some offices continue to use mercury cuffs, although these are no longer com-
mercially available. Experts recommend that mercury cuffs, now modified to
minimize risk of environmental spill, can still be used for routine office measure-
ments and evaluating the accuracy of nonmercury devices.42

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THE VITAL SIGNS

Making Accurate Blood Pressure Measurements. Take the time
to make sure your BP measurement will be accurate. Proper technique is
important and reduces the inherent variability arising from the patient or
examiner, the equipment, and the procedure itself.36

Selecting the Correct Size Blood Pressure Cuff

It is important for clinicians and patients to use a cuff that fits the patient’s arm.

Follow the guidelines outlined here for selecting the correct size:

● Width of the inflatable bladder of the cuff should be about 40% of upper arm

circumference (about 12 to 14 cm in the average adult).
● Length of the inflatable bladder should be about 80% of upper arm circumfer-

ence (almost long enough to encircle the arm).
● The standard cuff is 12 × 23 cm, appropriate for arm circumferences up to 28 cm.

If the cuff is too small (narrow), the
blood pressure will read high; if the
cuff is too large (wide), the blood
pressure will read low on a small arm
and high on a large arm.

Steps to Ensure Accurate Blood Pressure
Measurement

1. The patient should avoid smoking, caffeine, or exercise for 30 minutes prior
to measurement.

2. The examining room should be quiet and comfortably warm.
3. The patient should sit quietly for 5 minutes in a chair with feet on the floor,

rather than on the examining table.

4. The arm selected should be free of clothing, fistulas for dialysis, scars from
brachial artery cutdowns, or lymphedema from axillary node dissection or

radiation therapy.

5. Palpate the brachial artery to confirm a viable pulse and position the arm so
that the brachial artery, at the antecubital crease, is at heart level—roughly
level with the fourth interspace at its junction with the sternum.

6. If the patient is seated, rest the arm on a table a little above the patient’s
waist; if standing, try to support the patient’s arm at the midchest level.

If the brachial artery is below heart
level, the blood pressure reading will

be higher; if the brachial artery is

above heart level, the reading will be

lower.

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THE VITAL SIGNS

Position the Cuff and Arm. With the arm at heart level, center the inflat-
able bladder over the brachial artery. The lower border of the cuff should be
about 2.5 cm above the antecubital crease. Secure the cuff snugly. Slightly flex
the patient’s arm at the elbow.

Estimate the Systolic Pressure and Add 30 mm Hg. To decide how
high to raise the cuff pressure, first estimate the systolic pressure by palpation.
As you palpate the radial artery with the fingers of one hand, rapidly inflate the
cuff until the radial pulse disappears. Read this pressure on the manometer and
add 30 mm Hg. Using this sum for subsequent inflations prevents discomfort
from unnecessarily high cuff pressures. It also avoids the occasional error caused
by an auscultatory gap—a silent interval that may be present between the systolic
and the diastolic pressures (Fig. 4-5). Deflate the cuff promptly and completely
and wait for 15 to 30 seconds.

Position the Stethoscope Bell Over the Brachial Artery. Now
place the bell of a stethoscope lightly over the brachial artery, taking care to
make an air seal with the full rim (Fig. 4-6). Because the sounds to be heard,
the Korotkoff sounds, are relatively low in pitch, they are generally better
heard with the bell.

A loose cuff or a bladder that balloons

outside the cuff leads to falsely high

readings.

An unrecognized auscultatory gap

may lead to serious underestimation

of systolic pressure (150 instead of

200 in the example below) or overesti-

mation of diastolic pressure.

F I G U R E 4 – 6 . Place the bell over the brachial artery.

200

160

120

80

40

0

m
m

H
g

Systolic
pressure

Auscultatory gap

Diastolic
pressure

F I G U R E 4 – 5 . Auscultatory gap.

If you find an auscultatory gap, record

your findings completely (e.g., 200/98

with an auscultatory gap from 170 to

150).

An auscultatory gap (Fig. 4-6) is asso-

ciated with arterial stiffness and ath-

erosclerotic disease.43

E X A M P L E S O F A B N O R M A L I T I E S

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Beginning the Physical Examination: General Survey, Vital Signs, and Pain 129

THE VITAL SIGNS

Identify the Systolic Blood Pressure. Inflate the cuff again rapidly to
the target level, and then deflate the cuff slowly at a rate of about 2 to 3 mm Hg
per second. Note the level when you hear the sounds of at least two consecutive
beats. This is the systolic pressure (Fig. 4-7).

120

160

80

40

m
m

H
g

Arterial
pulse
tracing

Effect of cuff
on arterial blood flow

Auscultatory
findings

Artery
occluded;
no flow

Artery
compressed;
blood flow
audible

Artery not
compressed;
flow free
and inaudible

Silence

Silence

Systolic
pressure

Diastolic
pressure

Sounds of
turbulent flow

F I G U R E 4 – 7 . Auscultating systolic and diastolic Koratkoff sounds.

Identify the Diastolic Blood Pressure. Continue to deflate the cuff
slowly until the sounds become muffled and disappear. To confirm the disap-
pearance point, listen as the pressure falls another 10 to 20 mm Hg. Then
deflate the cuff rapidly to zero. The disappearance point, which is usually only
a few mm Hg below the muffling point, provides the best estimate of diastolic
pressure (Fig. 4-7).

Average Two or More Readings. Read both the systolic and the diastolic
levels to the nearest 2 mm Hg. Wait 2 or more minutes and repeat. Average your
readings. If the first two readings differ by more than 5 mm Hg, take additional
readings.

When using an aneroid instrument, hold the dial so that it faces you directly.
Avoid slow or repetitive inflations of the cuff because the resulting venous con-
gestion can cause false readings.

In some people, the muffling point and

the disappearance point are farther

apart. Occasionally, as in aortic regur-

gitation, the sounds never disappear. If

the difference is 10 mm Hg or greater,

record both figures (e.g., 154/80/68).

By making the sounds less audible,

venous congestion may produce arti-

ficially low systolic and high diastolic

pressures.

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THE VITAL SIGNS

Measure Blood Pressure in Both Arms At Least Once. Normally, there
may be a difference in pressure of 5 mm Hg and sometimes up to 10 mm Hg.
Subsequent readings should be made on the arm with the higher pressure.

Classification of Normal and Abnormal Blood Pressure. The
Seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure Report recommends using the mean of two or more properly
measured seated blood pressure readings, taken on two or more office visits, for
establishing of the blood pressure. The blood pressure measurement should be
verified in the contralateral arm.36 This report identifies four levels of systolic and
diastolic hypertension, affirmed by the American Society of Hypertension in
2013.44 Note that either component may be high. In 2013, the Eighth Joint
National Committee (JNC 8) issued the JNC 8 report based on rigorous scientific
review of clinical trial data.35 This report focuses more narrowly on thresholds
and goals for pharmacologic treatment. For patients ages ≥18 years to <60 years
in the general population, JNC 8 recommends treatment to lower blood pressure
for a diastolic blood pressure of ≥90 (strong evidence) and systolic blood pressure
of ≥140 (expert opinion). For patients ages ≥60 years, JNC 8 recommends
treatment for blood pressures ≥150/90. The JNC 8 report also recommends a
higher treatment threshold than JNC 7 for patients with diabetes and chronic
kidney disease (CKD), ≥140/90.

A pressure difference of more than 10

to 15 mm Hg occurs in subclavian steal
syndrome, supravalvular aortic steno-
sis, and aortic dissection, and should
be investigated.

Blood Pressure Classification for Adults (JNC 8,
American Society of Hypertension, JNC 7)35,36,44

Category Systolic (mm Hg) Diastolic (mm Hg)

Normal36

Prehypertension36,44

Stage 1 hypertension35

Ages ≥18 to <60 years;
diabetes or renal

disease

Age ≥60 yearsa

Stage 2 hypertension36,44

<120
120–139

140–159

150–159

≥160

<80
80–89

90–99

90–99

≥100
aThe American Society of Hypertension raises this cutoff to age ≥80 years.

Assessment of hypertension also

includes its effects on target “end

organs”—the eyes, heart, brain, and

kidneys. Look for hypertensive retinop-

athy, left ventricular hypertrophy, and

neurologic deficits suggesting stroke.

Renal assessment requires urinalysis

and blood tests of renal function.

When the systolic and diastolic levels fall in different categories, use the higher
category. For example, 170/92 mm Hg is stage 2 hypertension; 135/98 mm Hg
is stage 1 hypertension. In isolated systolic hypertension, systolic blood pressure is
≥140 mm Hg, and diastolic blood pressure is <90 mm Hg.

Treatment of isolated systolic hyper-
tension in patients ages ê60 years
reduces mortality and complications

from cardiovascular disease. The prev-

alence of isolated systolic hyperten-

sion in Americans ages 18 to 49 years

is increasing, also placing them at

higher cardiovascular risk.45,46

E X A M P L E S O F A B N O R M A L I T I E S

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Beginning the Physical Examination: General Survey, Vital Signs, and Pain 131

THE VITAL SIGNS

Low Blood Pressure. Interpret relatively low levels of blood pressure in
the light of past readings and the patient’s clinical state.

Orthostatic Hypotension. If indicated, assess orthostatic hypotension,
common in older adults. Measure blood pressure and heart rate in two
positions—supine after the patient is resting from 3 to 10 minutes, then within
3 minutes once the patient stands up. Normally, as the patient rises from the
horizontal to the standing position, systolic pressure drops slightly or remains
unchanged, whereas diastolic pressure rises slightly. Orthostatic hypotension is
a drop in systolic blood pressure of at least 20 mm Hg or in diastolic blood
pressure of at least 10 mm Hg within 3 minutes of standing.47,48

Special Situations

Weak or Inaudible Korotkoff Sounds. Consider technical problems
such as erroneous placement of your stethoscope, failure to make full skin
contact with the bell, and venous engorgement of the patient’s arm from repeated
inflations of the cuff. Also consider the possibilities of vascular disease or shock.
When you cannot hear Korotkoff sounds at all, alternative methods using a
Doppler probe or direct arterial pressure tracings may be necessary.

White Coat Hypertension. Encourage the patient to relax and remeasure
the blood pressure later in the encounter. Consider automated office readings or
ambulatory recordings.

The Obese or Very Thin Patient. For the obese arm, use a cuff 16 cm
in width. If the upper arm is short despite a large circumference, use a thigh cuff
or a very long cuff. If the arm circumference is >50 cm and not amenable to use
of a thigh cuff, wrap an appropriately sized cuff around the forearm, hold the
forearm at heart level, and feel for the radial pulse.42 Other options include using
a Doppler probe at the radial artery or an oscillometric device. For the very thin
arm, consider using a pediatric cuff.

Arrhythmias. Irregular rhythms produce variations in pressure and
therefore unreliable measurements. Ignore the effects of an occasional premature
contraction. With frequent premature contractions or atrial fibrillation, determine
the average of several observations and note that your measurements are
approximate. Ambulatory monitoring for 2 to 24 hours is recommended.42

The Hypertensive Patient with Systolic Blood Pressure Higher
in the Arms than in the Legs. Compare blood pressure in the arms and
the legs and assess “femoral delay” at least once in every hypertensive patient.

â–  Coarctation of the aorta arises from narrowing of the thoracic aorta, usually
distal to origin of the left subclavian artery, and classically presents with
systolic hypertension greater in the arms than the legs. In normal patients,
the systolic blood pressure should be 5 to 10 mm Hg higher in the lower
extremities than in the arms.

A pressure of 110/70 mm Hg would

usually be normal, but could also

indicate significant hypotension if

past pressures have been high.

Causes of orthostatic hypotension
include drugs, moderate or severe

blood loss, prolonged bed rest, and

diseases of the autonomic nervous

system.

See Chapter 20, Physical Examination

of the Older Adult, pp. 989–997.

In rare cases, patients are pulseless

due to occlusive disease in the

arteries of all the limbs from Takayasu
arteritis, giant cell arteritis, or
atherosclerosis.

See definition of white coat

hypertension on p. 126.

Using a small cuff overestimates

systolic blood pressure in obese

patients.49

Detection of an irregularly irregular

rhythm suggests atrial fibrillation. For
all irregular patterns, obtain an ECG to

identify the type of rhythm.

In coarctation of the aorta and occlusive
aortic disease there is systolic hyper-
tension in the upper extremities and

lower blood pressure in the legs, and

diminished or delayed femoral pulses,

sometimes termed femoral delay.50

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THE VITAL SIGNS

â–  To determine blood pressure in the leg, use a wide, long thigh cuff that
has a bladder size of 18 × 42 cm, and apply it to the midthigh. Center
the bladder over the posterior surface, wrap it securely, and listen over
the popliteal artery. If possible, the patient should be prone. Alterna-
tively, ask the supine patient to flex one leg slightly, with the heel resting
on the bed.

â–  Palpate the radial or brachial and the femoral pulses at the same time, and
compare their volume and timing. Normally, volume is equal and the pulses
occur simultaneously.

Heart Rate and Rhythm

Examine the arterial pulses, the heart rate and rhythm, and the amplitude and
contour of the pulse wave.

Heart Rate. The radial pulse is
commonly used to assess the heart
rate (Fig. 4-8). With the pads of
your index and middle fingers,
compress the radial artery until a
maximal pulsation is detected. If the
rhythm is regular and the rate seems
normal, count the rate for 30 seconds
and multiply by 2. If the rate is
unusually fast or slow, count for
60 seconds. The usual range of
normal is 60 to 90 to 100 beats per
minute.51

Rhythm. Begin by palpating the radial pulse. If there are any irregularities,
assess the rhythm at the apex by listening with your stethoscope. Premature
beats of low amplitude may not be transmitted to the peripheral pulses, leading
to underestimates of the heart rate. 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?

Respiratory Rate and Rhythm

Observe the rate, rhythm, depth, and effort of breathing. Count the number of res-
pirations in 1 minute either by visual inspection or by subtly listening over the
patient’s trachea with your stethoscope during your examination of the head and
neck or chest. Normally, adults take approximately 20 breaths per minute in a
quiet, regular pattern. An occasional sigh is normal. Check to see if expiration is
prolonged.

F I G U R E 4 – 8 . Palpate the radial pulse.

An elevated resting heart rate is asso-

ciated with increased risk of cardio-

vascular disease and mortality.52

See Table 9-1, Selected Heart Rates

and Rhythms, p. 400, and Table 9-2,

Selected Irregular Rhythms, p. 401.

Always check an ECG to identify the

type of rhythm.

Prolonged expiration is common in

COPD.

E X A M P L E S O F A B N O R M A L I T I E S

See Table 8-4, Abnormalities in Rate

and Rhythm of Breathing, p. 335.

C H A P T E R 4 |

Beginning the Physical Examination: General Survey, Vital Signs, and Pain 133

THE VITAL SIGNS

Temperature

The core body temperature, measured internally, is approximately 37°C (98.6°F)
and fluctuates approximately 1°C over the course of the day. It is lowest in the
early morning and highest in the afternoon and evening. Women have a wider
range of normal temperature than men.53

Although the research gold standard for core body temperature is the blood
temperature in the pulmonary artery, clinical practice relies on noninvasive
oral, rectal, axillary, tympanic membrane, and temporal artery measure-
ments.44 Tympanic membrane and temporal artery temperatures use infrared
thermometry.

â–  Oral and rectal temperature measurements remain common. Oral tempera-
tures are generally lower than the core body temperature. They are also lower
than rectal temperatures by an average of 0.4 to 0.5°C (0.7 to 0.9°F), and
higher than axillary temperatures by approximately 1°. Axillary temperatures
take 5 to 10 minutes to register and are considered less accurate than other
measurements.

â–  Tympanic membrane temperatures can be more variable than oral or rectal
temperatures. Studies vary in methodology, but suggest that in adults, oral
and temporal artery temperatures correlate more closely with the pulmonary
artery temperature, but are about 0.5°C lower.54–56

Oral Temperatures. For oral temperatures, options include electronic or
glass thermometers. Due to breakage and mercury exposure, glass thermometers
are being replaced by electronic thermometers. If using an electronic thermometer,
carefully place the disposable cover over the probe and insert the thermometer
under the tongue. Ask the patient to close both lips, and then watch closely for
the digital readout. An accurate temperature recording usually takes about
10 seconds.

For glass thermometers, shake the thermometer down to 35°C (96°F) or below,
insert it under the tongue, instruct the patient to close both lips, and wait for 3
to 5 minutes. Then read the thermometer, reinsert it for a minute, and read it
again. If the temperature is still rising, repeat this procedure until the reading
remains stable. Note that hot or cold liquids, and even smoking, can alter the
temperature reading. In these situations, delay taking the temperature for 10 to
15 minutes.

Rectal Temperatures. For a rectal temperature, ask the patient to lie on
one side with the hip flexed. Select a rectal thermometer with a stubby tip,
lubricate it, and insert it about 3 cm to 4 cm (1.5 inches) into the anal canal,
in a direction pointing to the umbilicus. Remove it after 3 minutes, then
read. Alternatively, use an electronic thermometer after lubricating the probe
cover. Wait about 10 seconds for the digital temperature recording to
appear.

Fever, or pyrexia, refers to an elevated
body temperature. Hyperpyrexia
refers to extreme elevation in temper-

ature, above 41.1°C (106°F), whereas

hypothermia refers to an abnormally
low temperature, below 35°C (95°F)

rectally.

Causes of fever include infection,
trauma such as surgery or crush inju-

ries, malignancy, drug reactions, and

immune disorders such as collagen

vascular disease.

The chief cause of hypothermia is
exposure to cold. Other causes

include reduced movement as in

paralysis, interference with vasocon-

striction from sepsis or excess alcohol,

starvation, hypothyroidism, and

hypoglycemia. Older adults are espe-

cially susceptible to hypothermia and

also less likely to develop fever.

Rapid respiratory rates tend to

increase the discrepancy between

oral and rectal temperatures. In these

situations, rectal temperatures are

more reliable.

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134 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

ACUTE AND CHRONIC PAIN

Tympanic Membrane Temperatures. The tympanic membrane shares
the same blood supply as the hypothalamus, where temperature regulation
occurs in the brain. Accurate temperature readings require access to the tympanic
membrane. Make sure the external auditory canal is free of cerumen, which can
lower temperature readings. Position the probe in the canal so that the infrared
beam is aimed at the tympanic membrane, or otherwise the measurement will
be invalid. Wait for 2 to 3 seconds until the digital temperature reading appears.

Temporal Artery Temperatures. This method takes advantage of the
location of the temporal artery, which branches off the external carotid artery and
lies within a millimeter of the skin surface of the forehead, cheek, and behind the
ear lobes. Place the probe against the center of the forehead, depress the infrared
scanning button, and brush the device across the forehead, down the cheek, and
behind an earlobe. Read the display, which records the highest measure
temperature. Industry information suggests that combined forehead and behind-
the-ear contact is more accurate than scanning only the forehead.

Chronic pain may be a spectrum dis-

order related to mental health and

somatic conditions. See Chapter 5,

Behavior and Mental Status, Symp-

toms and Behavior, pp. 148–153.

Numerous validated brief screening

tools are available for office use.58,61

See Chapter 3, The Seven Attributes

of a Symptom, p. 79.

E X A M P L E S O F A B N O R M A L I T I E S

Acute and Chronic Pain
Assessing Acute and Chronic Pain

The International Association for the Study of Pain defines pain as “an unpleasant
sensory and emotional experience” associated with tissue damage. The experi-
ence of pain is complex and multifactorial. Pain involves sensory, emotional, and
cognitive processing, but may lack a specific physical etiology.57

Chronic pain is defined in several ways: pain not associated with cancer or other
medical conditions that persists for more than 3 to 6 months; pain lasting more
than 1 month beyond the course of an acute illness or injury; or pain recurring
at intervals of months or years. Chronic noncancer pain affects an estimated 100
million Americans and 5% to 33% of patients in primary care settings.58,59 More
than 40% of patients report that their pain is poorly controlled. Treatment and
management represent a growing concern to leading educators and professional
societies, warranting a special report by the IOM in 2011 on Relieving Pain in
America, A Blueprint for Transforming Prevention, Care, Education, and Research58

and targeted interdisciplinary curricula.60

Adopt a multidisciplinary, measurement-based approach to assessing pain, care-
fully listening to the patient’s story, the many features of pain, and contributing
factors.58,61

The Patient’s History. Elicit the full history of the patient’s pain, tailoring
your approach to each patient’s unique experience. Ask the patient to describe
the pain and how it started. Is it related to a site of injury, movement, or time of
day? What is the quality of the pain—sharp, dull, burning? Ask if the pain
radiates or follows a particular pattern. What makes the pain better or worse?
Pursue the seven features of pain, as you would with any symptom. Ask the
patient to point to the pain because verbal descriptions can be imprecise.

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ACUTE AND CHRONIC PAIN

Ask about treatments that the patient has tried, including medications, physical
therapy, and alternative medicines. A comprehensive medication history identi-
fies drugs that interact with analgesics and reduce their efficacy.

Explore any comorbid conditions such as arthritis, diabetes, HIV/AIDS, sub-
stance abuse, sickle cell disease, or psychiatric disorders. These can have signifi-
cant effects on the patient’s experience of pain.

Chronic pain is the leading cause of disability and impaired performance at
work. Inquire about the effects of pain on the patient’s daily activities, mood,
sleep, work, and sexual activity.

Assessing Severity of the Pain. Use a consistent method to assess
pain severity. Three scales are common: the Visual Analog Scale and two
scales using ratings from 1 to 10—the Numeric Rating Scale and the Wong-
Baker FACES Pain Rating Scale. Numerous more detailed multidimensional
tools like the Brief Pain Inventory and the McGill Pain Questionnaire are
also available, but take longer to administer.62 The Wong-Baker FACES®
Pain Raiting Scale can be used by children as well as patients with language
barriers or cognitive impairment.63 The Faces Pain Scale by the International
Association for the Study of Pain64 is reproduced in Figure 4-9.

0 2 4 6 8 10

F I G U R E 4 – 9 . Pain rating scale. Explain to the person that each face is for a person

who feels happy because he has no pain (hurt) or sad because he has some or a lot of

pain. Face 0 is very happy because he doesn’t hurt at all. Face 2 hurts just a little bit.
Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10
hurts as much as you can imagine, although you don’t have to be crying to feel this

bad. Ask the person to choose the face that best describes how he is feeling. (Faces Pain
Scale—Revised (FPS-R). www.iasp-pain.org/fpsr. Copyright © 2001, International Association for the Study of Pain®. Reproduced

with permission.)

Health Disparities. Health disparities in pain treatment and delivery of
care are well documented, ranging 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.58 Studies show that
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 as first steps to ensure
uniform and effective pain management.

Types of Pain. Review the summary of types of pain on the next page to aid
in your diagnosis and management.66

See IOM report, Unequal Treatment:
Confronting Racial and Ethnic
Disparities in Health Care, 2002.65

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136 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

ACUTE AND CHRONIC PAIN

Types of Pain

Nociceptive
(somatic)

Nociceptive (somatic) pain is linked to tissue damage

to the skin, musculoskeletal system, or viscera (vis-

ceral pain), but the sensory nervous system is intact,

as in arthritis or spinal stenosis. It can be acute or

chronic. It is mediated by the afferent A-delta and

C-fibers of the sensory system. The involved afferent

nociceptors can be sensitized by inflammatory medi-

ators and modulated by both psychological processes

and neurotransmitters like endorphins, histamines,

acetylcholine, serotonin, norepinephrine, and

dopamine.

Neuropathic pain Neuropathic pain is a direct consequence of a lesion
or disease affecting the somatosensory system. Over

time, neuropathic pain may become independent of

the inciting injury, becoming burning, lancinating, or

shock-like in quality, It may persist even after healing

from the initial injury has occurred. Mechanisms pos-

tulated to evoke neuropathic pain include central ner-

vous system brain or spinal cord injury from stroke or

trauma; peripheral nervous system disorders causing

entrapment or pressure on spinal nerves, plexuses, or

peripheral nerves; and referred pain syndromes with

increased or prolonged pain responses to inciting stim-

uli. These triggers appear to induce changes in pain

signal processing through “neuronal plasticity,” lead-

ing to pain that persists beyond healing from the initial

injury.

Central
sensitization

In central sensitization pain, there is alteration of central
nervous system processing of sensation, leading to

amplification of pain signals. There is a lower pain

threshold to nonpainful stimuli, and the response to pain

may be more severe than expected. Mechanisms are the

subject of ongoing research. An example is fibromyalgia,

which has a strong overlap with depression, anxiety, and

somatization disorders and responds best to medica-

tions that modify neurotransmitters like serotonin and

dopamine.

Psychogenic pain Psychogenic pain involves the many factors that influence
the patient’s report of pain—psychiatric conditions like

anxiety or depression, personality and coping style, cul-

tural norms, and social support systems.

Idiopathic pain Idiopathic pain is pain without an identifiable etiology.

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ACUTE AND CHRONIC PAIN

Managing Chronic Pain. Managing pain is a complex clinical challenge.
Experts recommend a stepped-care approach, with an emphasis on measurement
and tracking tools to follow responses to treatment and referrals to specialists,
summarized below.67

Managing Chronic Pain: Steps for
Measurement-Based Care

Step 1: Measure pain intensity and pain interference. A validated two-item
questionnaire is available for primary care asking patients to rate pain in

the past month and interference with daily activities on a scale of 1 to 10.61

Step 2: Measure mood. Treatable depression, anxiety, and posttraumatic stress
disorder (PTSD) frequently accompany chronic pain. The PHQ-4 is a

4-item questionnaire for detecting anxiety and depression.68 The

Primary Care-PTSD is a 4-question screen for PTSD.69

Step 3: Measure the effect of pain on sleep. Opioid doses correlate with sleep-
disordered breathing and sleep apnea.

Step 4: Measure risk of co-occurring substance abuse, estimated at 18% to
30%.

Step 5: Measure the opioid dose and calculate the opioid dose equivalency using
available web-based calculators.

Source: Tauben D. Chronic pain management: measurement-based stepped care solutions. Pain:

Clinical Updates. International Association for the Study of Pain. December 2012. Available at

http://www.iasp-pain.org/PublicationsNews/NewsletterIssue.aspx?ItemNumber=2064. Accessed
January 28, 2015.

Treating pain requires sophisticated knowledge of nonopioid, opioid, and
adjuvant analgesics and behavioral and physical therapy, areas that are beyond
the scope of this book. Over recent decades, clinicians have become increas-
ingly attentive to chronic pain in response to numerous guidelines for treat-
ment and care. In parallel, prescriptions for some opioids have increased more
than 800% in the past 10 years.70 Roughly a third of all patients with chronic
noncancer pain, or more than 3% of U.S. adults, take opioids, primarily for
arthritis and low back pain.71 At the same time, rates of death from opioid
overdose among medically prescribed opioid users have climbed to 148 per
100,000.72 Recent studies show that the death rate is directly related to the
maximum prescribed dose of daily opioids. Risk of overdose increases more
than four- to eightfold for patients taking the highest doses, namely 100 mg/
day or more.72,73 Risk factors for fatal overdose include age 65 years or older,
depression, substance abuse, and concurrent benzodiazepine treatment. To
avoid such hazards, make a commitment to acquiring skills in pain assessment
and therapeutics, and take advantage of the validated substance abuse screen-
ing and brief intervention protocols that have been shown to reduce substance-
use–related problems.74–77

Focus on the Four A’s to monitor
patient outcomes:

● Analgesia

● Activities of daily living

● Adverse effects

● Aberrant drug-related behaviors

See Chapter 3, Interviewing and the

Health History, for definitions of

tolerance, physical dependence, and

addiction, p. 96.

E X A M P L E S O F A B N O R M A L I T I E S

138 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

RECORDING YOUR FINDINGS

Your write-up of the physical examination begins with a general description of
the patient’s appearance, based on the General Survey. Note that initially you
may use sentences to describe your findings; later you will use phrases. The style
below contains phrases appropriate for most write-ups.

Recording the Physical Examination—The
General Survey and Vital Signs

Choose vivid and graphic adjectives, as if you are painting a picture in words.

Avoid clichés such as “well-developed,” “well-nourished,” or “in no acute dis-

tress,” because they are too general to convey the special features of the patient

before you.

Record the vital signs taken at the time of your examination rather than

earlier in the day. (Common abbreviations for blood pressure, heart rate, and

respiratory rate are self-explanatory.)

“Mrs. Scott is a young, healthy-appearing woman, well-groomed, fit, and

cheerful. Height is 5′4″, weight 135 lbs, BMI 24, BP 120/80, right and left arms,
HR 72 and regular, RR 16, temperature 37.5°C.”
OR
“Mr. Jones is an elderly man who looks pale and chronically ill. He is alert, with

good eye contact but unable to speak more than two or three words at a time

due to shortness of breath. He has intercostal muscle retraction when breathing

and sits upright in bed. He is thin, with diffuse muscle wasting. Height is 6′2″,
weight 175 lbs, BP 160/95, right arm, HR 108 and irregular, RR 32 and labored,

temperature 101.2°F.”

These findings suggest exacerbation

of COPD.

E X A M P L E S O F A B N O R M A L I T I E S

Recording Your Findings

C H A P T E R 4 |

Beginning the Physical Examination: General Survey, Vital Signs, and Pain 139

Table 4-1 Obesity-Related Health Conditions

Cardiovascular
â–  Hypertension
â–  Coronary artery disease
â–  Atrial fibrillation
â–  Heart failure
â–  Cor pulmonale
â–  Varicose veins

Endocrine
â–  Metabolic syndrome
â–  Type 2 diabetes
â–  Dyslipidemia
â–  Polycystic ovarian syndrome/androgenicity
â–  Amenorrhea/infertility/menstrual disorders

Gastrointestinal
â–  Gastroesophageal reflux disease (GERD)
â–  Nonalcoholic fatty liver disease (NAFLD)
â–  Cholelithiasis
â–  Hernias
â–  Cancer: colon, pancreas, esophagus, liver

Genitourinary
â–  Urinary stress incontinence
â–  Obesity-related glomerulopathy
â–  Hypogonadism (male)
â–  Cancer: breast, cervical, ovarian, uterine
â–  Pregnancy complications
â–  Nephrolithiasis, chronic renal disease

Integument
â–  Striae distensae (stretch marks)
â–  Status pigmentation of legs
â–  Lymphedema
â–  Cellulitis
â–  Intertrigo, carbuncles
â–  Acanthosis nigricans/skin tags

Musculoskeletal
â–  Hyperuricemia and gout
â–  Immobility
â–  Osteoarthritis (knees, hips)
â–  Low back pain

Neurologic
â–  Stroke
â–  Idiopathic intracranial hypertension
â–  Meralgia paresthetica

Psychological
â–  Depression/low self-esteem
â–  Body image disturbance
â–  Social stigmatization

Respiratory
â–  Dyspnea
â–  Obstructive sleep apnea
â–  Hypoventilation syndrome/Pickwickian syndrome
â–  Pulmonary embolism
â–  Asthma

Used with permission from Kushner RF. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion—Assessment and Management of Adult
Obesity: A Primer for Physicians. Chicago, IL: American Medical Association; 2003. © American Medical Association 2003. All Rights Reserved.

140 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G140 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

Table 4-2 Eating Disorders and Excessively Low BMI

In the United States, an estimated 5 to 10 million women and 1 million men suffer from eating disorders. The lifetime prevalence
estimates for anorexia nervosa, bulimia nervosa, and binge eating disorders are 0.9%, 1.5%, and 3.5%, respectively, among
women; and 0.3%, 0.5%, and 2.0%, respectively, among men. These severe disturbances of eating behavior are often difficult to
detect, especially in teens wearing baggy clothes or in individuals who binge and then induce vomiting or evacuation. Be familiar
with the two principal eating disorders, anorexia nervosa and bulimia nervosa. Both conditions are characterized by distorted
perceptions of body image and weight. Early detection is important because prognosis improves when treatment occurs in the
early stages of these disorders.

Clinical Features

Anorexia Nervosa Bulimia Nervosa
â–  Refusal to maintain minimally normal body weight (or BMI

above 17.5 kg/m2)
â–  Afraid of gaining weight or becoming fat
â–  Frequently starving but in denial; lacking insight
â–  Often brought in by family members
â–  May present as failure to make expected weight gains in

childhood or adolescence, amenorrhea in women, loss of
libido or potency in men

â–  Associated with depressive symptoms such as depressed
mood, irritability, social withdrawal, insomnia, decreased
libido

â–  Additional features supporting diagnosis: self-induced
vomiting or purging, excessive exercise, use of appetite
suppressants and/or diuretics

â–  Biologic complications
â–  Gynecological: amenorrhea
â–  Endocrine: hypercortisolemia, hypoglycemia, osteoporosis,

euthyroid hypothyroxinemia
â–  Cardiovascular disorders: bradycardia, hypotension,

arrhythmias, cardiomyopathy
â–  Metabolic disorders: hypokalemia, hypochloremic metabolic

alkalosis, increased blood urea nitrogen (BUN), edema
â–  Other: dry skin, dental caries, delayed gastric emptying,

constipation, anemia, fatigue, weakness

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

â–  Often with normal weight
â–  Overeating at least once a week during 3-month period;

large amounts of food consumed in short period (∼2 hrs)
â–  Preoccupation with eating; craving and compulsion to eat;

lack of control over eating; alternating with periods of
starvation

â–  Dread of fatness (usually leading to underweight)
â–  Subtypes of

â–  Purging: bulimic episodes accompanied by self-induced
vomiting or use of laxatives, diuretics, or enemas

â–  Nonpurging: bulimic episodes accompanied by
compensatory behavior such as fasting, or excessive
exercising

â–  Biologic complications. See changes listed for anorexia
nervosa, especially weakness, fatigue, mild cognitive
disorder; also erosion of dental enamel, parotid gland
swelling, pancreatitis, mild neuropathies, seizures,
hypokalemia, hypochloremic metabolic acidosis,
hypomagnesemia

Sources: Hudson JI, Hiripi E, Pope HG Jr, et al. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry.
2007;61:348; World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: World Health
Organization, 1993; American Psychiatric Association. DSM-5: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric
Association, 2013; Andersen AE. Eating Disorders: In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. New York,
NY: Wolters Kluwer; Lippincott Williams & Wilkins, 2009.

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Beginning the Physical Examination: General Survey, Vital Signs, and Pain 141

Table 4-3 Nutrition Screening

Mini Nutritional Assessment
MNA®

Last name: First name:

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

Screening

A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or
swallowing difficulties?
0 = severe decrease in food intake
1 = moderate decrease in food intake
2 = no decrease in food intake

B Weight loss during the last 3 months
0 = weight loss greater than 3 kg (6.6 lbs)
1 = does not know
2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)
3 = no weight loss

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

D Has suffered psychological stress or acute disease in the past 3 months?
0 = yes 2 = no

E Neuropsychological problems
0 = severe dementia or depression
1 = mild dementia
2 = no psychological problems

F1 Body Mass 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 greater

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 appropriate numbers. Total the numbers for the final screening score.

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

Screening score (max. 14 points)

12 – 14 points: Normal nutritional status
8 – 11 points: At risk of malnutrition
0 – 7 points: Malnourished

References
1. Vellas B, Villars H, Abellan G, et al. Overview of the MNA® – Its History and Challenges. J Nutr Health Aging. 2006;10:456-465.
2. Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for Undernutrition in Geriatric Practice: Developing the Short-Form Mini

Nutritional Assessment (MNA-SF). J. Geront. 2001; 56A: M366-377
3. Guigoz Y. The Mini-Nutritional Assessment (MNA ) Review of the Literature – What does it tell us? J Nutr Health Aging. 2006; 10:466-487.
4. Kaiser MJ, Bauer JM, Ramsch C, et al. Validation of the Mini Nutritional Assessment Short-Form (MNA®-SF): A practical tool for

identification of nutritional status. J Nutr Health Aging. 2009; 13:782-788.
® 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

3 = CC 31 or greater

142 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G142 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

Table 4-4 Obesity: Stages of Change Model
and Assessing Readiness

Stage Characteristic Patient Verbal Cue
Appropriate
Intervention Sample Dialogue

Precontemplation Unaware of problem,
no interest in change

“I’m not really interested in
weight loss. It’s not a
problem.”

Provide information
about health risks and
benefits of weight loss

“Would you like to read
some information about
the health aspects of
obesity?”

Contemplation Aware of problem,
beginning to think of
changing

“I know I need to lose
weight, but with all that’s
going on in my life right
now, I’m not sure I can.”

Help resolve
ambivalence; discuss
barriers

“Let’s look at the benefits
of weight loss, as well as
what you may need to
change.”

Preparation Realizes benefits of
making changes and
thinking about how to
change

“I have to lose weight, and
I’m planning to do that.”

Teach behavior
modification; provide
education

“Let’s take a closer look at
how you can reduce some
of the calories you eat and
how to increase your
activity during the day.”

Action Actively taking steps
toward change

“I’m doing my best. This is
harder than I thought.”

Provide support and
guidance, with a focus
on the long term

“It’s terrific that you’re
working so hard. What
problems have you had so
far? How have you solved
them?”

Maintenance Initial treatment goals
reached

“I’ve learned a lot through
this process.”

Relapse control “What situations continue
to tempt you to overeat?
What can be helpful for
the next time you face
such a situation?”

Sources: American Medical Association. Roadmaps for Clinical Practice—Case Studies in Disease Prevention and Health Promotion—Assessment and Management
of Adult Obesity: A Primer for Physicians. Communication and Counseling Strategies. Booklet 8. Chicago, November 2003. Adapted from Prochaska JO,
DiClemente CC. Toward a comprehensive model of change. In: Miller WR, ed. Treating Addictive Behaviors. New York, NY: Plenum, 1986:3.

Table 4-5 Nutrition Counseling: Sources of Nutrients

Nutrient Food Source

Calcium Dairy foods such as milk, natural cheeses, and yogurt
Calcium-fortified cereals, fruit juice, soy milk, and tofu
Dark green leafy vegetables like collard, turnip, and mustard greens; kale; bok choy
Sardines

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

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

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

Source: Adapted from U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. Washington,
DC: U.S. Government Printing Office; 2010; Choose MyPlate.gov. Available at http://www.choosemyplate.gov/index.html. Accessed December 15, 2014; Office 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.

Table 4-6 Patients with Hypertension: Recommended
Changes in Diet

Dietary Change Food Source

Increase foods high in
potassium

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

Decrease foods high in
sodium

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

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

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144 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

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57. International Association for the Study of Pain. IASP Taxonomy.
Updated May 2012. Available at http://www.iasp-pain.org/
Taxonomy?navItemNumber=576. Accessed January 28, 2015.

58. Institute of Medicine. Relieving Pain in America: A Blueprint for
Transforming Prevention, Care, Education, and Research (2011).
Available at http://www.nap.edu/download.php?record_id=
13172. Accessed January 28, 2015.

59. Breuer B, Cruciani R, Portenoy RK. Pain management by primary
care physicians, pain physicians, chiropractors, and acupunctur-
ists: a national survey. South Med J. 2010;103:738.

60. International Association for the Study of Pain. IASP Interprofes-
sional Pain Curriculum Online. Updated January 2014. Available
at http://www.iasp-pain.org/Education/CurriculumDetail.aspx?
ItemNumber = 2057. Accessed January 29, 2015.

61. Washington State Agency Medical Directors’ Group. Interagency
Guideline On Opioid Dosing For Chronic Non-Cancer Pain: An Educa-
tion Aid To Improve Care And Safety With Opioid Treatment. Olympia,
Washington: Washington State Department of labor and Indus-
tries, 2010. Available at http://www.agencymeddirectors.wa.gov/
opioiddosing.asp. Accessed January 28, 2015.

62. Keller S, Bann CM, Dodd SL, et al. Validity of the brief pain inven-
tory for use in documenting the outcomes of patients with noncan-
cer pain. Clin J Pain. 2004;20:309.

63. Bieri D, Reeve R, Champion GD, et al. The Faces Pain Scale for the
self-assessment of the severity of pain experienced by children:
development, initial validation and preliminary investigation for
ratio scale properties. Pain. 1990;41:139.

64. International Society for the Study of Pain. Faces Pain Scale–
Revised Home. Updated September 2014. Available at http://www.
i a s p – p a i n . o r g / E d u c a t i o n / C o n t e n t . a s p x ? I t e m N u m b e r =
1519&navItemNumber=577. Accessed January 28, 2015.

65. Smedley BR, Stith AY, Nelson AR, eds. Committee on Understanding
and Eliminating Racial and Ethnic Disparities in Health Care. Unequal
Treatment: Confronting Racial and Ethnic Disparities in Health Care.
Washington, DC: National Academies Press; 2002.

66. Haanpaa M, Attal N, Backonja M, et al. NeuPSIG guidelines on
neuropathic pain assessment. Pain. 2011;152:14.

67. Tauben D. Chronic pain management: measurement-based
stepped care solutions. Pain: Clinical Updates. International Asso-
ciation for the Study of Pain. December 2012. Available at http://
w w w. i a s p – p a i n . o rg / P u b l i c a t i o n s N e w s / N e w s l e t t e r I s s u e .
aspx?ItemNumber=2064. Accessed January 28, 2015.

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REFERENCES

68. Kroenke K, Spitzer RL, Williams JB, et al. An ultra-brief screening
scale for anxiety and depression: the PHQ-4. Psychosomatics.
2009;50:613.

69. Ouimette P, Wade M, Prins A, et al. Identifying PTSD in primary
care: comparison of the Primary Care-PTSD screen (PC-PTSD) and
the General Health Questionnaire-12 (GHQ). J Anxiety Disord.
2008;22:337.

70. McClellan TA, Turner BJ. Chronic non-cancer pain management
and opioid overdose: time to change prescribing practices. Ann
Intern Med. 2010;152:123.

71. Altman RD, Smith HS. Opioid therapy for osteoarthritis and
chronic low back pain. Postgrad Med. 2010;122:87.

72. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for
chronic pain and overdose. A cohort study. Ann Intern Med.
2010;152:85.

73. Bohnert AS, Valenstein M, Bair MJ, et al. Association between opi-
oid prescribing patterns and opioid overdose-related deaths.
JAMA. 2011;305:1315.

74. Madras BK, Compton WM, Avula D, et al. Screening, brief inter-
ventions, referral to treatment (SBIRT) for illicit drug and alcohol
use at multiple healthcare sites: comparison at intake and 6 months
later. Drug Alcohol Depend. 2009;99:280.

75. Gilron I, Watson PN, Cahill CM, et al. Neuropathic pain: a practi-
cal guide for the clinician. CMAJ. 2006;175:256.

76. Butler SF, Budman SH, Fernandez K, et al. Validations of a screener
and opioid assessment measure for patients with chronic pain.
Pain. 2004;112(1–2):65.

77. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-
treated patients: preliminary validation of the Opioid Risk Tool.
Pain Med. 2005;6:432.

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Behavior and Mental Status 147

As clinicians, we are uniquely poised to detect clues to mental illness and harm-
ful behavior through empathic listening and close observation. Nonetheless,
these clues are often missed. Recognizing mental illness is especially important
given its significant prevalence and morbidity, the high likelihood that it is treat-
able, the shortage of psychiatrists, and the increasing importance of primary care
clinicians as the first to encounter the patient’s distress.1,2 The prevalence of
mental health disorders in U.S. adults in 2012 was 18%, affecting 43.7 million
people; yet, only 41% received treatment.3 Even for those receiving care, adher-
ence to treatment guidelines in primary care offices is <50% and disproportion-
ately lower for ethnic minorities.4–6

C H A P T E R

5
Behavior and Mental Status

The Bates’ suite offers these additional resources to enhance learning and facilitate
understanding of this chapter:
■ Bates’ Pocket Guide to Physical Examination and History Taking, 8th edition
■ Bates’ Visual Guide to Physical Examination
â–  thePoint online resources, for students and instructors: http://thepoint.lww.com

F I G U R E 5 – 1 . Assessment of

mental status can be challenging.

See Chapter 17, The Nervous System,

pp. 711–796.

Recognizing Mental Disorders

This chapter presents:

● Common symptoms and behaviors suggestive of mental health disorders
● Concepts that guide history taking and the general assessment of mental

health
● Priorities for mental health promotion and counseling, and
● Components of the mental status examination, a structured framework for for-

mal assessment of behavioral and mental health disorders, and a major com-

ponent of the examination of the nervous system (Fig. 5-1).

Mental health disorders are commonly masked by other clinical conditions,
calling for sensitive and careful inquiry. Learn to look for the interaction of
anxiety and depression in patients with substance abuse, termed “dual diagno-
sis,” because both must be treated for the patient to achieve optimal function.
Watch for underlying psychiatric conditions in “difficult encounters” and
patients with unexplained symptoms.7 Explore the outlook of patients with

148 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

SYMPTOMS AND BEHAVIOR

chronic illness, a group that is especially vulnerable to depression and anxiety.8

Finally, bear in mind that nearly half of those with any single mental disorder
meet the criteria for one or more additional disorders, with severity strongly
related to comorbidity.9

See Table 5-1, Somatic Symptom and

Related Disorders, p. 169, for types

of somatic symptom disorders and

guidelines for management.

Symptoms and Behavior

Understanding Symptoms:
What Do They Mean?

Changing Paradigms for Understanding Symptoms. Sorting
the array of symptoms encountered in an office visit is an ongoing challenge.
Unlike physical signs, symptoms are not observable. Traditionally, dualistic or
binary explanatory models of symptoms have prevailed. Symptoms have been
viewed as psychological, reflecting a mental or emotional state, or physical,
relating to a body sensation such as pain, fatigue, or palpitations. Physical
symptoms, often termed somatic in the mental health literature, prompt more
than 50% of U.S. office visits.10 Common somatic complaints include: pain
from headache, backache, or musculoskeletal conditions; gastrointestinal
symptoms; sexual or reproductive symptoms; and neurologic symptoms such
as dizziness or loss of balance.

Approximately 5% of somatic symptoms are acute, triggering immediate evalua-
tion.11 Another 70% to 75% are minor or self-limited and resolve in 6 weeks. Nev-
ertheless, approximately 25% of patients have persisting and recurrent symptoms
that elude assessment and fail to improve. Overall, 30% of symptoms are medically
unexplained. Some involve single complaints that persist longer than others, for
example, back pain, headache, or musculoskeletal pain. Others present as clusters
in functional syndromes, such as irritable bowel syndrome, fibromyalgia, chronic
fatigue, temporomandibular joint disorder, and multiple chemical sensitivity.

Experts now propose that physical and psychological symptoms are interactive
and represent “a varying mix of disease and nondisease input” that lies along a
spectrum from medical to mental disorders.11 Evidence shows that symptom
etiology is often multifactorial, lacking a single cause; and that often, there are
several related symptoms or symptom clusters rather than single complaints.
The integrative continuum model leads to explanations that are less likely to be
“simplified, reductionistic, or mechanistic.” Watch for emerging schemas that
place symptoms along a causative spectrum with five nodal points: symptoms
like wheezing, with a clear medical cause; functional somatic syndromes like
irritable bowel syndrome; “symptom-only diagnoses” such as low back pain;
symptoms associated with psychological conditions, like fatigue in depression;
and finally, medically unexplained symptoms.

Changes have also occurred in the classification of somatic syndromes in the
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) of
2013. When patients have “distressing somatic symptoms plus abnormal
thoughts, feelings, and behaviors in response to these symptoms,” clinicians can

E X A M P L E S O F A B N O R M A L I T I E S

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Behavior and Mental Status 149

SYMPTOMS AND BEHAVIOR

consider the diagnosis of somatic symptom and related disorders.12 These patients
have prominent somatic symptoms associated with significant distress and
impairment and are seen more often in primary care and medical settings than
in psychiatric and mental health settings. They may have accompanying medical
disorders. The DSM-5 notes that “a distinctive characteristic of the many indi-
viduals with somatic symptom disorder is not the somatic symptoms per se, but
instead the way they present and interpret them.” This change in diagnostic
criteria emphasizes the presence of positive symptoms, and moves away from
relying on medically unexplained symptoms and the absence of a medical cause,
which can be difficult to determine. The prevalence of somatic symptom disor-
ders is estimated at 5% to 7%.

Medically Unexplained Symptoms. Patients with medically unexplained
symptoms fall into heterogeneous groupings ranging from selected impairment
to behaviors meeting DSM-5 criteria for mood and somatic symptom disorders.13,14
Many patients do not report symptoms of anxiety and depression, the most
common mental health disorders in the general population, but focus on physical
concerns instead (Fig. 5-2). Two-thirds of patients with depression, for example,
present with physical complaints, and half report multiple unexplained or
somatic symptoms.14 Furthermore, functional syndromes have been shown to
“frequently co-occur and share key symptoms and selected objective
abnormalities.”15 Overlap rates for fibromyalgia and chronic fatigue syndrome in
an analysis of 53 studies ranged from 34% to 70%. Failure to recognize the
admixture of physical symptoms, functional syndromes, and common mental
disorders—anxiety, depression, unexplained and somatoform symptoms, and
substance abuse—add to the burden of patient undertreatment and poor quality
of life. Authors of the first randomized controlled intervention trial for patients
with medically unexplained symptoms advise viewing such symptoms as “a
generalized warning sign of underlying psychological distress, of which
depression is an advanced manifestation.”16

The “Difficult Encounter.” Patients with unexplained and somatic symp-
toms are often frequent users of the health care system and labeled as “difficult
patients.” Patient depression and anxiety “make physician ratings of difficult
encounters three times more likely, and somatization increases this likelihood
nine-fold.”17 A growing literature reveals that 15% to 20% of primary care visits,
or up to three to four visits a day, are considered difficult.7 In the difficult encoun-
ter dyad, clinician factors have emerged that include job stress and burnout,
anxiety and depression in the clinician, less clinical experience, and aversion to
the psychosocial aspects of care.18,19 Clinicians are urged to identify the many
variables associated with these encounters, identify their own underlying nega-
tive emotions, adapt their approach and redirect the encounter, and explore what
makes the encounter difficult with the patient.20,21 In the words of an expert:

“Celebrate the well-navigated difficult encounter. Dealing with difficulty signifies
mastery rather than weakness. Olympic dives are rated in terms of difficulty, as
are mountain climbs, hiking trails, musical works, crossword puzzles, and highly
technical procedures. Partnering with patients in the challenging aspects of their
health, lives, or medical care is a stepping stone to surmounting together the diffi-
cult encounter.”7

F I G U R E 5 – 2 . Clinicians often

encounter symptoms not easily

diagnosed.

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Mental Health Screening

Unexplained conditions lasting more than 6 weeks are increasingly recognized
as chronic disorders that should prompt screening for depression, anxiety, or
both. Because screening all patients is time consuming and expensive, experts
recommend a two-tier approach: brief screening questions with high sensitivity
and specificity for patients at risk, followed by more detailed investigation when
indicated.

Several groups of patients warrant brief screening because of high risk of coex-
isting depression and anxiety. Recent studies have helped clarify overlap symp-
toms and functional syndromes and provide streamlined practical screening tools
suitable for office care.27 A well-established instrument to aid in office diagnosis
is the PRIME-MD (Primary Care Evaluation of Mental Disorders); however, it

Mental Disorders and Unexplained Symptoms
in Primary Care Settings

Mental Disorders in Primary Care
● Approximately 20% of primary care outpatients have mental disorders,

but 50% to 75% of these disorders are undetected and untreated.22,23

● Prevalence of mental disorders in primary care settings is roughly as

follows22,24–26:
● Anxiety—20%
● Mood disorders including dysthymia, depressive, and bipolar disor-

ders—25%
● Depression—10%
● Somatoform disorders—10% to 15%
● Alcohol and substance abuse—15% to 20%

Explained and Unexplained Symptoms
● Physical symptoms account for approximately 50% of office visits.
● Roughly one-third of physical symptoms are unexplained; in 20% to 25% of

patients, physical symptoms become chronic or recurring.10,14

● In patients with unexplained symptoms, the prevalence of depression and anxi-
ety exceeds 50% and increases with the total number of reported physical

symptoms,10,14 making detection and “dual diagnosis” important clinical goals.

Common Functional Syndromes
● Co-occurrence rates for common functional syndromes such as irritable bowel

syndrome, fibromyalgia, chronic fatigue, temporomandibular joint disorder,

and multiple chemical sensitivity reach 30% to 90%, depending on the disor-

ders compared.15

● The prevalence of symptom overlap is high in the common functional syn-
dromes namely, complaints of fatigue, sleep disturbance, musculoskeletal

pain, headache, and gastrointestinal problems.
● The common functional syndromes also overlap in rates of functional impair-

ment, psychiatric comorbidity, and response to cognitive and antidepressant

therapy.

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SYMPTOMS AND BEHAVIOR

contains 26 questions and takes up to 10 minutes to complete.25 The DSM-5
acknowledges the diagnostic challenges facing primary care providers and has
reduced the total number of disorders as well as their subcategories in the
reclassification of Somatic Symptoms and Related Disorders. Improved screen-
ing tools for office use and management will continue to emerge.

Patient Indications for Mental Health Screening

● Medically unexplained physical symptoms—more than half have depression

or anxiety disorder
● Multiple physical or somatic symptoms or “high symptom count”
● High severity of the presenting somatic symptom
● Chronic pain
● Symptoms for more than 6 weeks
● Physician rating as a “difficult encounter”
● Recent stress
● Low self-rating of overall health
● Frequent use of health care services
● Substance abuse

Chronic pain may be a spectrum dis-

order in patients with anxiety, depres-

sion, or somatic symptoms. See

Chapter 4, Beginning the Physical

Examination: General Survey, Vital

Signs, and Pain, pp. 111–146.

High-Yield Screening Questions for Office Practice

Depression
● Over the past 2 weeks, have you felt down, depressed, or hopeless?22,28,29

● Over the past 2 weeks, have you felt little interest or pleasure in doing things

(anhedonia)?

Anxiety
Anxiety disorders include generalized anxiety disorder, social phobia, panic

disorder, posttraumatic stress disorder, and acute stress disorder.30–33

● Over the past 2 weeks, have you been feeling nervous, anxious, or on edge?
● Over the past 2 weeks, have you been unable to stop or control worrying?
● Over the past 4 weeks, have you had an anxiety attack—suddenly feeling fear

or panic?

Illness Anxiety Disorder (Replaces Hypochondriasis in DSM-5)
● Whiteley Index: 14-item self-rating scale34,35

Substance-Related and Addictive Disorders
● CAGE questions adapted for alcohol and drug abuse—see Chapter 3, Inter-

viewing and the Health History, p. 97.

Multidimensional
● PRIME-MD (Primary Care Evaluation of Mental Disorders) for the five most

common disorders in primary care: depression, anxiety, alcohol, somatoform,

and eating disorders; 26-item patient questionnaire followed by clinician

evaluation; takes approximately 10 minutes.36

● PRIME-MD Patient Health Questionnaire, available as patient health ques-

tionnaire for self-rating; takes approximately 3 minutes.36

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152 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

SYMPTOMS AND BEHAVIOR

Personality Disorders. Patients with personality disorders can also
display problematic office behaviors that escape diagnosis. The DSM-5
characterizes these disorders as “an enduring pattern of inner experience and
behavior that deviates markedly from the expectations of the individual’s
culture, is pervasive and inflexible, has an onset in adolescence or early
adulthood, is stable over time, and leads to distress or impairment.” These
patients have dysfunctional interpersonal coping styles that disrupt and
destabilize their relationships, including those with health care providers. A
recent study reports an overall prevalence of 9%, with prevalence of the three
subcomponent clusters of 5.7% for odd and eccentric disorders; 1.5% for
dramatic, emotional, or erratic disorders; and 6% for anxious or fearful
disorders.12 Personality disorders co-occur at high frequencies with alcohol
and substance abuse and with the axis I disorders of depression, anxiety
disorders, bipolar disorder, attention deficit hyperactivity disorder, autism
spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia.37
Note that DSM-5 section II continues “the categorical perspective that personality
disorders are qualitatively distinct clinical syndromes.” Section III presents an
alternative approach to guide further research, namely a dimensional perspective
that characterizes personality disorders as “impairments in personality
functioning and pathological personality traits” that “merge imperceptibly into
normality and into one another.” For more detailed diagnostic criteria, beyond
the scope of this book, consult the DSM-5.

Personality Disorders: DSM-5 Section II

Cluster/Personality Type Characteristic Behavior Patterns

A: Odd or Eccentric Disorders
● Paranoid
● Schizoid
● Schizotypal

Distrust and suspiciousness

Detachment from social relations

with a restricted emotional range

Eccentricities in behavior and cogni-

tive distortions; acute discomfort

in close relationships

B: Dramatic, Emotional or Erratic Disorders
● Antisocial
● Borderline
● Histrionic
● Narcissistic

Disregard for, and violation of, the

rights of others

Instability in interpersonal relation-

ships, self-image and affective

regulation; impulsivity

Excessive emotionality and attention

seeking

Persisting grandiosity, need for admi-

ration and lack of empathy

(continued )

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Behavior and Mental Status 153

THE HEALTH HISTORY

Borderline Personality Disorder. Patients with borderline personality
disorders are especially challenging. These patients show “a pervasive pattern of
instability of interpersonal relationships, self-image, and affects, and marked
impulsivity.”12 They make “frantic efforts to avoid real or imagined abandonment”
and show recurrent suicidal behavior, gestures, or threats, or self-mutilating behav-
ior. Prevalence in primary care practices is 6%, though the diagnosis is often
missed.38,39 More than 90% of patients with this disorder meet criteria for other
personality disorders. Many have coexisting mood, anxiety, and substance abuse
disorders. Presenting symptoms overlap with depression, anxiety, substance abuse,
and eating disorders, which complicate diagnosis. In clinical settings, over 75% of
those affected are women, and the disorder shows a strong genetic and familial
pattern.40 More than half lose their jobs because of interpersonal problems, and
roughly one-third experience sexual abuse. Patients often report feeling depressed
and empty, with mood swings that spiral out of control leading to feelings of rage,
sadness, and anxiety. To clinicians, these patients may appear demanding, disrup-
tive, or manipulative. Recognition of borderline features is essential for patient
understanding, reduction of patient self-harm, and referral for expert evaluation.

Personality Disorders: DSM-5 Section II (continued )

Cluster/Personality Type Characteristic Behavior Patterns

C: Anxious or Fearful Disorders
● Avoidant
● Dependent
● Obsessive–compulsive

Social inhibition, feelings of inadequacy

and hypersensitivity to negative

evaluation

Submissive and clinging behavior

related to an excessive need to be

taken care of

Preoccupation with orderliness, per-

fectionism, and control

Note that in DSM-5, the dimensional model reduces these disorders to six categories: antisocial,
avoidant, borderline, narcissistic, obsessive–compulsive, and schizotypal, and emphasizes self and

interpersonal functioning.

Sources: Adapted from Schiffer RB. Ch 420, Psychiatric disorders in medical practice, in Cecil Textbook of
Medicine, 22nd ed. Philadelphia: Saunders, 2004, p. 2628; American Psychiatric Association. Diagnostic

and Statistical Manual of Mental Disorders, 5th Ed. Washington, DC: American Psychiatric Press, 2013.

Common or Concerning Symptoms

● Changes in attention, mood, or speech
● Changes in insight, orientation, or memory
● Anxiety, panic, ritualistic behavior, and phobias
● Delirium or dementia

The Health History

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THE HEALTH HISTORY

Overview. As you interact with the patient, you will quickly observe the
patient’s level of alertness and orientation, and mood, attention, and memory.
While the history unfolds, you will learn about the patient’s insight and judgment,
as well as any recurring or unusual thoughts or perceptions. These and other
components of mood and cognition will alert you to conditions that require
more detailed follow-up, including a formal mental status examination and
possible referral.

Many of the terms pertinent to the mental health history and the mental status
examination are familiar from social conversation. It is important to learn their
precise meanings in the context of the formal evaluation of mental status, detailed
in the box below.

See Techniques of Examination for the

formal mental status examination on

pp. 158–168.

Terminology: The Mental Status Examination

Level of
Consciousness

Alertness or State of Awareness of the
Environment

Attention The ability to focus or concentrate over time on a
particular stimulus or activity—an inattentive

person is easily distractible and may have

difficulty giving a history or responding to

questions.

Memory The process of registering or recording information,
tested by asking for immediate repetition of

material, followed by storage or retention of

information. Recent or short-term memory covers
minutes, hours, or days; remote or long-term memory
refers to intervals of years.

Orientation Awareness of personal identity, place, and time;
requires both memory and attention

Perceptions Sensory awareness of objects in the environment
and their interrelationships (external stimuli);

also refers to internal stimuli such as dreams or

hallucinations.

Thought processes The logic, coherence, and relevance of the patient’s
thought as it leads to selected goals; how people
think

Thought content What the patient thinks about, including level of
insight and judgment

Insight Awareness that symptoms or disturbed behaviors
are normal or abnormal; for example, distinguishing

between daydreams and hallucinations that

seem real.

Judgment Process of comparing and evaluating alternatives
when deciding on a course of action; reflects values

that may or may not be based on reality and social

conventions or norms

(continued )

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Behavior and Mental Status 155

THE HEALTH HISTORY

Terminology: The Mental Status
Examination (continued )

Level of
Consciousness

Alertness or State of Awareness of the
Environment

Affect A fluctuating pattern of observable behaviors that
expresses subjective feelings or emotions through

tone of voice, facial expression, and demeanor.

Disturbed affect may be flat, blunted, labile, or

inappropriate.

Mood A more pervasive and sustained emotion that colors
the person’s perception of the world. (Affect is to

mood as weather is to climate.) Mood may be

euthymic (in the normal range), elevated, or

dysphoric (unpleasant, possibly as sad, anxious, or

irritable), for example.

Language A complex symbolic system for expressing, receiving,
and comprehending words; as with consciousness,

attention, and memory, language is essential for

assessing other mental functions

Higher cognitive
functions

Assessed by vocabulary, fund of information, abstract

thinking, calculations, construction of objects that

have two or three dimensions

Attention, Mood, Speech, Insight, Orientation, Memory. Assess
the patient’s level of consciousness; general appearance; mood, including
depression or mania; and ability to pay attention, remember, understand, and
speak. Place the patient’s vocabulary and general fund of information in the
context of his or her cultural and educational background. The patient’s
account of illness and life circumstances often tells you about insight and
judgment. If you suspect a problem in orientation and memory, you can ask,
“Let’s see, your last clinic appointment was when . . . ?” “And the date today?”
Try to integrate your evaluation of mental status into the history so it will
seem less like an interrogation.

Anxiety, Panic, Ritualistic Behavior, Phobias. Explore any unusual
thoughts, preoccupations, beliefs, or perceptions as they come up during the
interview. For example, excessive worry persisting over a 6-month period
suggests a possible anxiety disorder, one of the most prevalent psychiatric
conditions in the United States, with a lifetime prevalence of approximately
3%.12 Over time, you will recognize some of its mimics: panic disorder, with
recurrent panic attacks followed by a period of anxiety about further attacks;
obsessive–compulsive disorder, with intrusive thoughts and ritualistic behaviors;
posttraumatic stress disorder, characterized by re-experiencing, avoidance,
persistent negative alterations in cognition and mood, and alterations in arousal
and reactivity; and social anxiety disorder, with its marked anticipatory anxiety
in social situations. Supplement your interview with questions in specific areas
and pursue a formal mental status examination when indicated.

See Table 17-6, Disorders of Speech,

p. 784.

Compulsions, obsessions, phobias, and
anxieties are seen in mood disorders.
For official diagnostic criteria of anxi-

ety disorders, see Diagnostic and
Statistical Manual of Mental Disorders
(DSM-5).

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156 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

HEALTH PROMOTION AND COUNSELING

Neurocognitive Disorders: Delirium and Dementia. In the
DSM-5, delirium and dementia fall under the new category of neurocognitive
disorders, based on consultation with expert groups. Dementia is classified as a
major cognitive disorder; a less severe level of cognitive impairment is now mild
neurocognitive disorder, which applies to younger individuals with impairment
from traumatic brain injury or HIV infection. The DSM-5 retains the term
dementia, however, due to widespread clinical usage. Helpful tables provide
working definitions of each cognitive domain, with examples of symptoms
related to everyday activities and related assessments.

A wide range of patients in clinical practice warrant assessment of mental status:
patients with brain injury, psychiatric symptoms, or reports from family members
of vague or changed behavior; patients with subtle behavioral changes, difficulty
taking medications as prescribed, problems attending to household chores or pay-
ing bills, or loss of interest in their usual activities; and patients with change in
orientation after surgery or during an acute illness. Identify these problems promptly
because they impact family relationships, work status, and possible disability.

See Table 20-2, Neurocognitive Disor-

ders: Delirium and Dementia, p. 1001.

See also discussions in Chapter 17,

The Nervous System, pp. 711–796

and in Chapter 20, The Older Adult,

pp. 955–1008.

Important Topics for Health Promotion
and Counseling

● Screening for depression and suicidality
● Screening for substance use disorders, including alcohol and prescription drugs

Mental health disorders impose a substantial burden of suffering.41 About 1 in 5
U.S. adults (43.7 million) experience mental illness in a given year, with about
1 in 25 (9.6 million) experiencing serious mental illness (schizophrenia, major
depression, or bipolar disorder). Depression and anxiety disorders are a com-
mon cause of hospitalization in the United States, and mental illness is associated
with increased risks for chronic medical conditions, decreased life expectancy,
disability, substance abuse, and suicide.

Mood Disorders and Depression. Depressive and bipolar disorders
affect over 9% of the U.S. population.42,43 About 16 million adult Americans, or
almost 7%, have major depression, often with coexisting anxiety disorders and
substance abuse. Depression is nearly twice as common in women as men; the
prevalence of postpartum depression is 7% to 13%.44 Depression frequently
accompanies chronic medical illness. High-risk patients may have subtle early
signs of depression, including low self-esteem, loss of pleasure in daily activities
(anhedonia), sleep disorders, and difficulty concentrating or making decisions.

See Chapter 3, Interviewing and the

Health History, pp. 65–108.

E X A M P L E S O F A B N O R M A L I T I E S

Health Promotion and
Counseling: Evidence and
Recommendations

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HEALTH PROMOTION AND COUNSELING

Look carefully for symptoms of depression in vulnerable patients, especially those
who are young, female, single, divorced or separated, seriously or chronically ill,
bereaved, or have other psychiatric disorders, including substance abuse. A
personal or family history of depression also places patients at risk.

The U.S. Preventive Services Task Force (USPSTF) made a grade B recommendation
in 2009 for depression screening in clinical settings that can provide care supports and
accurate diagnosis, treatment, and follow-up.28 Performing screening in less support-
ive settings received only a grade C recommendation. Asking two simple questions
about mood and anhedonia appears to be as effective as using more detailed instru-
ments. A positive test response has a sensitivity of 83% and a specificity of 92% for
detecting major depression.45 All positive screening tests warrant full diagnostic inter-
views. Failure to diagnose depression can have fatal consequences—the presence of
an affective disorder is associated with an 11-fold increased risk for suicide.46

Suicide. Suicide ranks as the 10th leading cause of death in the United States,
accounting for nearly 40,000 deaths. Annually, there are almost 13 completed
suicides per 100,000 population.47–49 Suicide is the second leading cause of death
among 15- to 24-year olds. Suicide rates are highest among those ages 45 to
54 years, followed by elderly adults ≥age 85 years. Men have suicide rates nearly
four times higher than women, though women are three times more likely to
attempt suicide. Men are most likely to use firearms to commit suicide, while
women are most likely to use poison. Overall, suicides in non-Hispanic whites
account for about 90% of all suicides, though American Indian/Alaska Native
women ages 15 to 24 years have the highest suicide rates of any racial/ethnic
group. An estimated 25 attempts are made for each death by suicide, with ratios of
100 to 200 to 1 among young adults. In 2011, nearly 16% of U.S. high school
students reported that they had seriously considered attempting suicide in the
previous year. Despite the public health burden of suicide, the USPSTF has
concluded that the current evidence is insufficient to assess the balance of benefits
and harms of screening for suicide risk in a primary care setting—a grade I
recommendation,50 but statistics underscore the importance of investigating
patient clues and risk factors.

Substance Use Disorders, Including Alcohol and Prescription
Drugs. The harmful interactions between mental disorders and substance use
disorders also present a major public health problem. The 2013 National Survey
on Drug Use and Health showed that 23% of the U.S. population ages 12 years
or older (60.1 million people) reported binge drinking, and over 6% reported
heavy drinking.41 Over 24 million Americans (9.4% of the population) reported
use of an illicit drug during the month before the survey, including nearly 20
million marijuana users, 1.6 million cocaine users, and 6.5 million users of
prescription drugs for nonmedical indications. Nearly 22 million persons aged
12 years or older were classified as having a substance use disorder based on
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria.51 Only
about 2.5 million of these individuals received treatment at a specialty facility
for an illicit drug or alcohol problem. Rates of drug-induced deaths continue
to increase and are highest among whites and American Indian/Alaska Natives.
The Centers for Disease Control and Prevention reports that prescription drugs
have replaced illicit drugs as a leading cause of drug-induced deaths.52

See screening questions on p. 151

and review screening tools readily

available for office practice.

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158 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

TECHNIQUES OF EXAMINATION

Every patient should be asked about alcohol use, substance abuse, and misuse
of prescription drugs. The USPSTF has given a grade B recommendation to
screening adults ages 18 years and older for alcohol misuse, and providing brief
behavioral counseling for those engaging in risky or hazardous drinking.53 However,
the USPSTF has issued only a grade I (insufficient evidence) recommendation for
screening for illicit drug use.54

The Mental Status Examination

● Appearance and behavior
● Speech and language
● Mood
● Thoughts and perceptions
● Cognition, including memory, attention, information and vocabulary, calcula-

tions, abstract thinking, and constructional ability

The assessment of mental status is challenging and complex. Changes in mental
status warrant careful evaluation for underlying pathologic and pharmacologic
causes. The patient’s personality, psychodynamics, family and life experiences, and
cultural background all come into play. Amplify your findings from the history and
physical examination as you select all or part of the formal mental status examina-
tion for further testing. The Mental Status Examination is central to assessment in
psychiatric practice. It is also a critical element in the assessment of the nervous
system and the first segment of the nervous system write-up. Learn to describe the
patient’s mood, speech, behavior, and cognition and to relate these findings to your
examination of the cranial nerves, motor and sensory systems, and reflexes.

The Mental Status Examination consists of five components: appearance and
behavior; speech and language; mood; thoughts and perceptions; and cognitive
function. Cognitive function includes orientation, attention, memory, attention, and
higher cognitive functions such as information and vocabulary, calculations, abstract
thinking, and constructional ability. Prepare the patient for formal testing and explain
your rationale.

The format that follows should help structure your observations, but is not
intended as a step-by-step guide. Be flexible, but thorough. In some situations,
however, sequence is important. If the patient’s consciousness, attention, com-
prehension of words, and ability to speak are impaired, assess these deficits
promptly. If the patient cannot give a reliable history, testing most of the other
mental functions will be difficult and merits an evaluation for acute causes.

Appearance and Behavior

Integrate the observations you have made throughout the history and physical
examination, including the following.

See Chapter 17, Nervous System,

pp. 711–796, especially pp. 733–735

and Recording Your Findings, p. 773.

E X A M P L E S O F A B N O R M A L I T I E S

See discussion of screening tools in

Chapter 3, Interviewing and the

Health History, Alcohol and Prescrip-

tion and Illicit Drugs, pp. 96–97, and

Chapter 11, Abdomen, Screening for

Alcohol Abuse, pp. 464–466.

Techniques of Examination

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TECHNIQUES OF EXAMINATION

Level of Consciousness. Is the patient awake and alert? Does the patient
understand your questions and respond appropriately and reasonably quickly,
or tend to lose track of the topic, grow silent, or even fall asleep?

If the patient does not respond to your questions, escalate the stimulus in
steps:

â–  Speak to the patient by name and in a loud voice.

â–  Shake the patient gently, like wakening a sleeper.

If there is no response to these stimuli, promptly assess the patient for stupor or
coma—severe reductions in level of consciousness.

Posture and Motor Behavior. Does the patient sit or lie quietly or prefer
to walk around? Observe the patient’s posture and ability to relax. Note the pace,
range, and type of movement. Are movements voluntary and spontaneous? Are
any limbs immobile? Are posture and motor activity affected by topics under
discussion, type of activity, or who is in the room?

Dress, Grooming, and Personal Hygiene. How is the patient
dressed? Is the clothing clean and presentable? Is it appropriate for the patient’s
age and social group? Note the grooming of the patient’s hair, nails, teeth, skin,
and, if present, beard. How do the grooming and hygiene compare with peers of
comparable age, lifestyle, and socioeconomic group? Compare one side of the
body with the other.

Facial Expression. Observe the face both at rest and during conversation.
Watch for changes in expression. Are they appropriate for the topics being
discussed? Or is the face relatively immobile throughout?

Manner, Affect, and Relationship to People and Things. Assess
the patient’s affect, or external expression of the inner emotional state. Is it
appropriate to the topics being discussed? Or is the affect labile, blunted, or
flat? Does it seem exaggerated at certain points? If so, how? Observe the
patient’s openness, approachability, and reactions to others and the
surroundings. Does the patient hear or see things not present, or converse with
someone who is not there?

See the table on Level of Conscious-

ness (Arousal), Chapter 17, The

Nervous System, p. 769.

Lethargic patients are drowsy, but
open their eyes and look at you,

respond to questions, and then fall

asleep.

Obtunded patients open their eyes
and look at you, but respond slowly

and are somewhat confused.

Look for tense posture, restlessness,

and anxious fidgeting; the crying,

pacing, and hand-wringing of agi-
tated depression; the hopeless
slumped posture and slowed move-

ments of depression; the agitated
and expansive movements of a

manic episode.

Grooming and personal hygiene

may deteriorate in depression,
schizophrenia, and dementia. Exces-
sive fastidiousness may be seen in

obsessive–compulsive disorder. One-
sided neglect may result from a

lesion in the opposite parietal cor-

tex, usually the nondominant side.

Watch for the anger, hostility, suspi-

ciousness, or evasiveness of patients

with paranoia; the elation and
euphoria of mania; the flat affect
and remoteness of schizophrenia;
the apathy (dulled affect with

detachment and indifference) of

dementia; and anxiety or depression.
Hallucinations occur in schizophrenia,

alcohol withdrawal, and systemic

toxicity.

Note expressions of anxiety, depres-

sion, apathy, anger, elation, or facial

immobility in parkinsonism.

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TECHNIQUES OF EXAMINATION

Speech and Language

Throughout the interview, note the following characteristics of the patient’s
speech.

Quantity. Is the patient talkative or unusually silent? Are comments
spontaneous, or limited to direct questions?

Rate. Is speech fast or slow?

Volume. Is speech loud or soft?

Articulation of Words. Are the words clear and distinct? Does the speech
have a nasal quality?

Fluency. Fluency reflects the rate, flow, and melody of speech and the content
and use of words. Watch for abnormalities of spontaneous speech such as:

â–  Hesitancies and gaps in the flow and rhythm of words

â–  Disturbed inflections, such as a monotone

â–  Circumlocutions, in which phrases or sentences are substituted for a word
the person cannot think of, such as “what you write with” for “pen”

■ Paraphasias, in which words are malformed (“I write with a den”), wrong
(“I write with a bar”), or invented (“I write with a dar”).

If the patient’s speech lacks meaning or fluency, proceed with further testing as
outlined in the following box. A person who can write a correct sentence does
not have aphasia.

Note the slow speech of depression; the
accelerated louder speech of mania.

Dysarthria refers to defective articula-
tion. Aphasia is a disorder of language.
Dysphonia results from impaired vol-
ume, quality, or pitch of the voice. See

Table 17-6, Disorders of Speech, p. 784.

These abnormalities suggest aphasia
from cerebrovascular infarction.

Aphasia may be receptive (impaired
comprehension with fluent speech) or

expressive (with preserved compre-
hension and slow nonfluent speech).

Testing for Aphasia

Word Comprehension Ask the patient to follow a one-stage command,
such as “Point to your nose.” Try a two-stage com-

mand: “Point to your mouth, then your knee.”

Repetition Ask the patient to repeat a phrase of one-syllable
words (the most difficult repetition task): “No ifs,

ands, or buts.”

Naming Ask the patient to name the parts of a watch.
Reading Comprehension Ask the patient to read a paragraph aloud.
Writing Ask the patient to write a sentence.

These questions help identify the type

of aphasia. Check for deficits in vision,

hearing, intelligence, and education

which may affect responses. Two com-

mon kinds of aphasia—expressive
(Broca aphasia) and receptive (Wernicke
aphasia)—are compared in Table 17-6,

Disorders of Speech, p. 784.

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TECHNIQUES OF EXAMINATION

Mood

Ask the patient to describe his or her mood, including usual mood level and
fluctuations related to life events. “How did you feel about that?” for example,
or, more generally, “How is your overall mood?” The reports from family and
friends may be of value.

Has the mood been intense and unchanging, or labile? How long has it lasted?
Is it appropriate to the patient’s situation? If depression, have there been episodes
of an elevated mood, suggesting a bipolar disorder?

If you suspect depression, assess its severity and any risk of suicide. Ask . . .

â–  Do you feel discouraged or depressed?

â–  How low do you feel?

â–  What do you see for yourself in the future?

■ Do you ever feel that life isn’t worth living? Or that you want to be dead?

â–  Have you ever thought of killing yourself?

â–  How did (do) you think you would do it? Do you have a plan?

â–  What do you think would happen after you were dead?

It is your responsibility to ask directly about suicidal thoughts. This may be the
only way to uncover suicidal ideation and plans that launch immediate interven-
tion and treatment.

Thought and Perceptions

Thought Processes. Assess the logic, relevance, organization, and coherence
of the patient’s thought processes throughout the interview. Does speech progress
logically toward a goal? Listen for patterns of speech that suggest disorders of
thought processes, as outlined in the box below.

Moods range from sadness and melan-

choly; contentment, joy, euphoria, and

elation; anger and rage; anxiety and

worry; to detachment and indifference.

For official diagnostic criteria of

depressive and bipolar disorders, see

Diagnostic and Statistical Manual of
Mental Disorders (DSM-5).

Variations and Abnormalities in Thought
Processes

Circumstantiality The mildest thought disorder, consisting of speech

with unnecessary detail, indirection, and delay in

reaching the point. Some topics may have a mean-

ingful connection. Many people without mental

disorders have circumstantial speech.

Derailment (loosening

of associations)

“Tangential” speech with shifting topics that are

loosely connected or unrelated. The patient is

unaware of the lack of association.

(continued )

Circumstantiality occurs in people

with obsessions.

Derailment is seen in schizophrenia,

manic episodes, and other psychotic

disorders.

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162 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

TECHNIQUES OF EXAMINATION

Variations and Abnormalities in Thought
Processes (continued )

Flight of Ideas An almost continuous flow of accelerated speech

with abrupt changes from one topic to the next.

Changes are based on understandable associa-

tions, plays on words, or distracting stimuli, but

ideas are not well connected.

Neologisms Invented or distorted words, or words with new and

highly idiosyncratic meanings.

Incoherence Speech that is incomprehensible and illogical, with

lack of meaningful connections, abrupt changes in

topic, or disordered grammar or word use. Flight

of ideas, when severe, may produce incoherence.

Blocking Sudden interruption of speech in midsentence or

before the idea is completed, attributed to “losing

the thought.” Blocking occurs in normal people.

Confabulation Fabrication of facts or events in response to ques-

tions, to fill in the gaps from impaired memory.

Perseveration Persistent repetition of words or ideas.

Echolalia Repetition of the words and phrases of others.

Clanging Speech with choice of words based on sound, rather

than meaning, as in rhyming and punning. For

example, “Look at my eyes and nose, wise eyes

and rosy nose. Two to one, the ayes have it!”

Flight of ideas is most frequently

noted in manic episodes.

Neologisms are observed in

schizophrenia, psychotic disorders,

and aphasia.

Incoherence is seen in severe

psychotic disturbances (usually

schizophrenia).

Blocking may be striking in

schizophrenia.

Confabulation is seen in Korsakoff

syndrome from alcoholism.

Perseveration occurs in schizophrenia
and other psychotic disorders.

Echolalia occurs in manic episodes

and schizophrenia.

Clanging occurs in schizophrenia and

manic episodes.

Thought Content. To assess thought content, follow the patient’s leads
and cues rather than asking direct questions. For example, “You mentioned that
a neighbor caused your entire illness. Can you tell me more about that?” Or, in
another situation, “What do you think about at times like these?” For more
focused inquiries, be tactful and accepting. “When people are upset like this,
sometimes they can’t keep certain thoughts out of their minds,” or “ . . . things
seem unreal. Have you experienced anything like this?” In these ways, explore
any of the patterns in the following box.

Abnormalities of Thought Content

Compulsions Repetitive behaviors that the person feels driven to
perform in response to an obsession, aimed at

preventing or reducing anxiety or a dreaded event or

situation; these behaviors are excessive and

unrealistically connected to the provoking stimulus12

(continued )

Compulsions, obsessions, phobias,

and anxieties often occur in anxiety

disorders. See Diagnostic and
Statistical Manual of Mental Disorders
(DSM-5).

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TECHNIQUES OF EXAMINATION

Abnormalities of Thought Content (continued )

Obsessions Recurrent persistent thoughts, images, or urges experienced
as intrusive and unwanted that the person tries to ignore,

suppress, or neutralize with other thoughts or actions (for

example, performing a compulsive behavior)

Phobias Persistent irrational fears, accompanied by a
compelling desire to avoid the provoking stimulus

Anxieties Apprehensive anticipation of future danger or
misfortune accompanied by feelings of worry,

distress, and/or somatic symptoms of tension

Feelings of Unreality A sense that the environment is strange, unreal, or remote
Feelings of

Depersonalization
A sense that one’s self or identity is different, changed,

unreal; lost; or detached from one’s mind or body

Delusions False fixed personal beliefs that are not amenable
to change in light of conflicting evidence; types of

delusions include:
● Persecutory
● Grandiose
● Jealous
● Erotomanic—the belief than another person is in

love with the individual
● Somatic—involves bodily functions or sensations
● Unspecified—includes delusions of reference without

a prominent persecutory or grandiose component, or

the belief that external events, objects, or people have

a particular and unusual personal significance (for

example, commands from the radio or television)

Perceptions. Pursue false perceptions. For example, “When you heard the
voice speaking to you, what did it say? How did it make you feel?” Or, “After
you’ve been drinking a lot, do you ever see things that aren’t really there?” Or,
“Sometimes after major surgery like yours, people hear peculiar or frightening
things. Has anything like this happened to you?” In these ways, find out about
the following abnormal perceptions.

Delusions and feelings of unreality or

depersonalization are often associated

with psychotic disorders. For official
diagnostic criteria of psychotic disor-

ders, see Diagnostic and Statistical
Manual of Mental Disorders (DSM-5).

Abnormalities of Perception

Illusions Misinterpretations of real external stimuli, such as mistaking
rustling leaves for the sound of voices.12

Hallucina-
tions

Perception-like experiences that seem real but, unlike illusions,

lack actual external stimulation. The person may or may not

recognize the experiences as false. Hallucinations may be

auditory, visual, olfactory, gustatory, tactile, or somatic.

False perceptions associated with dreaming, falling asleep,

and awakening are not classified as hallucinations.

Illusions may occur in grief reactions,

delirium, acute and posttraumatic
stress disorders, and schizophrenia.

Hallucinations may occur in delirium,
dementia (less commonly), posttrau-
matic stress disorder, schizophrenia,
and alcoholism.

E X A M P L E S O F A B N O R M A L I T I E S

Delusions may also occur in delir-

ium, severe mood disorders, and

dementia.

164 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

TECHNIQUES OF EXAMINATION

Insight. Some of your first questions to the patient often yield important
information about insight: “What brings you to the hospital?” “What seems to
be the trouble?” “What do you think is wrong?” Note whether the patient is
aware that a particular mood, thought, or perception is abnormal or part of an
illness.

Judgment. Assess judgment by noting the patient’s responses to family
situations, jobs, use of money, and interpersonal conflicts. “How do you plan
to get help after leaving the hospital?” “How are you going to manage if you
lose your job?” “If your husband starts to abuse you again, what will you do?”
“Who will take care of your financial affairs while you are in the nursing
home?”

Note whether decisions and actions are based on reality or impulse, wish fulfill-
ment, or disordered thought content. What insights and values seem to underlie
the patient’s decisions and behavior? Allowing for cultural variations, how do
these compare with a comparable mature adult? Because judgment reflects matu-
rity, it may be variable and unpredictable during adolescence.

Cognitive Functions

Orientation. You can usually assess orientation during the interview. For
example, you can ask quite naturally for clarification about specific dates and
times, the patient’s address and telephone number, the names of family members,
or the route to the hospital. At times, direct questions will be needed: “Can you
tell me the time now . . . and what day it is?” Assess orientation to:

■ Person—the patient’s name, and names of relatives and professional
personnel

■ Time—the time of day, day of the week, month, season, date and year, dura-
tion of hospitalization

■ Place—the patient’s residence, the names of the hospital, city, and state

Attention. The following tests of attention are commonly used.

Digit Span. Explain that you would like to test the patient’s ability to con-
centrate, perhaps adding that this can be difficult if the patient is in pain or ill.
Recite a series of digits, starting with two at a time and speaking each number
clearly at a rate of about one per second. Ask the patient to repeat the numbers
back to you. If this repetition is accurate, try a series of three numbers, then four,
and so on as long as the patient responds correctly. Jot down the numbers as you
say them to ensure your own accuracy. If the patient makes a mistake, try once
more with another series of the same length. Stop after a second failure in a
single series.

When choosing digits, use street numbers, zip codes, telephone numbers, and
other numerical sequences that are familiar to you, but avoid consecutive

Patients with psychotic disorders

often lack insight into their illness.

Denial of impairment may accompany

some neurologic disorders.

Judgment may be poor in delirium,

dementia, intellectual disability, and

psychotic states. Anxiety, mood disor-

ders, intelligence, education, income,

and cultural values also influence

judgment.

Disorientation is common when

memory or attention is impaired,

as in delirium.

Causes of poor performance include

delirium, dementia, intellectual dis-
ability, and performance anxiety.

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TECHNIQUES OF EXAMINATION

numbers, easily recognized dates, and sequences that are familiar to the
patient.

Now, starting again with a series of two, ask the patient to repeat the numbers to
you backward.

Normally, a person should be able to repeat correctly at least five digits forward
and four backward.

Serial 7s. Instruct the patient, “Starting from a hundred, subtract 7, and
keep subtracting 7 . . . . ” Note the effort required and the speed and accuracy of
the responses. Writing down the answers helps you keep up with the arithmetic.
Normally, a person can complete serial 7s in 1½ minutes, with fewer than four
errors. If the patient cannot do serial 7s, try 3s or counting backward.

Spelling Backward. This can substitute for serial 7s. Say a five-letter
word, spell it, for example, W-O-R-L-D, and ask the patient to spell it backward.

Remote Memory. Inquire about birthdays, anniversaries, social security
number, names of schools attended, jobs held, or past historical events such as
wars relevant to the patient’s past.

Recent Memory. This can involve the events of the day. Ask questions with
answers you can check against other sources to see if the patient is confabulating,
or making up facts to compensate for a defective memory. These might include
the day’s weather or appointment time, current medications, or laboratory tests
taken during the day.

New Learning Ability. Give the patient three or four words such as “83,
Water Street, and blue,” or “table, flower, green, and hamburger.” Ask the patient to
repeat them so that you know that the information has been heard and registered.
This step, like digit span, tests registration and immediate recall. Then proceed to
other parts of the examination. After 3 to 5 minutes, ask the patient to repeat the
words. Note the accuracy of the response, awareness of whether it is correct, and any
tendency to confabulate. Normally, a person should be able to remember the words.

Higher Cognitive Functions

Information and Vocabulary. If observed clinically in the context of
cultural and educational background, information and vocabulary provide a
rough estimate of the patient’s baseline abilities. Begin assessing fund of
knowledge and vocabulary during the interview. Ask about work, hobbies,
reading, favorite television programs, or current events. Start with simple
questions, then move to more difficult questions. Note the person’s grasp of
information, complexity of the ideas, and choice of vocabulary.

Poor performance may result from

delirium, the late stage of dementia,

intellectual disability, anxiety, or

depression. Also consider educational

level.

Remote memory may be impaired in

the late stage of dementia.

Recent memory is impaired in demen-
tia and delirium. Amnestic disorders
impair memory or new learning ability

and reduce social or occupational

functioning, but lack the global fea-

tures of delirium or dementia. Anxiety,

depression, and intellectual disability

may also impair recent memory.

Information and vocabulary are rela-

tively unaffected by psychiatric disor-

ders except in severe cases. Testing

helps distinguish adults with life-long

intellectual impairment (whose infor-

mation and vocabulary are limited)

from those with mild or moderate

dementia (whose information and
vocabulary are fairly well preserved).

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More directly, you can ask about specific facts such as:

â–  The name of the president, vice president, or governor

â–  The names of the last four or five presidents

â–  The names of five large cities in the country

Calculating Ability. Test the patient’s ability to do arithmetical calculations,
starting with simple addition (“What is 4 + 3? . . . 8 + 7?”) and multiplication
(“What is 5 × 6? . . . 9 × 7?”). Proceed to more difficult tasks using two-digit
numbers (“15 + 12” or “25 × 6”) or longer, written examples.

Alternatively, pose practical functionally important questions, like: “If something
costs 78 cents and you give the clerk one dollar, how much should you get back?”

Abstract Thinking. Test the capacity to think abstractly in two ways.

Proverbs. Ask the patient what the following proverbs mean:

A stitch in time saves nine.

Don’t count your chickens before they’re hatched.

The proof of the pudding is in the eating.

A rolling stone gathers no moss.

The squeaky wheel gets the grease.

Note the relevance of the answers and their degree of concreteness or abstract-
ness. For example, “You should sew a rip before it gets bigger” is concrete,
whereas “Prompt attention to a problem prevents trouble” is abstract. Average
patients should give abstract or semiabstract responses.

Similarities. Ask the patient to tell you how the following are alike:
An orange and an apple A church and a theater

A cat and a mouse A piano and a violin

A child and a dwarf Wood and coal

Note the accuracy and relevance of the answers and their degree of concreteness
or abstractness. For example, “A cat and a mouse are both animals” is abstract,
“They both have tails” is concrete, and “A cat chases a mouse” is not relevant.

Constructional Ability. The task here is to copy figures of increasing
complexity onto a piece of blank unlined paper. Show each figure one at a time
and ask the patient to copy it as well as possible (Fig. 5-3).

Poor performance suggests dementia

or aphasia, but should be measured
against the patient’s fund of knowl-

edge and education.

Concrete responses are common in

people with intellectual disability,

delirium, or dementia, but may also
reflect limited education. Patients

with schizophrenia may respond
concretely or with personal and

bizarre interpretations.

E X A M P L E S O F A B N O R M A L I T I E S

With intact vision and motor ability,

poor constructional ability suggests

dementia or parietal lobe damage.

Intellectual disability can also impair

performance.

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TECHNIQUES OF EXAMINATION

F I G U R E 5 – 3 . Ask the patient to copy these figures.

F I G U R E 5 – 4 . Poor, fair, and good

shapes.

These three diamonds are rated poor,

fair, and good (but not excellent).55

F I G U R E 5 – 5 . Patient-drawn clock rated as excellent.

These three clocks are poor, fair, and

good.55

F I G U R E 5 – 6 . Poor, fair, and good

clocks.

Special Techniques

Mini-Mental State Examination (MMSE). This brief test has been
widely used to screen for cognitive dysfunction or dementia, and follow their
course over time. Although several versions are available on the internet,
copyright permission for use and reproduction is required. For more detailed
information regarding the MMSE, contact the publisher, Psychological
Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549,
or online: http://www4.parinc.com/. Below are some sample questions.

E X A M P L E S O F A B N O R M A L I T I E S

In another approach, ask the patient to draw a clock face complete with numbers
and hands (Fig. 5-5).

MMSE Sample Items

Orientation to Time
“What is the date?”

Registration
“Listen carefully. I am going to say three words. You say them back after I

stop. Ready? Here they are . . .

APPLE (pause), PENNY (pause), TABLE (pause). Now repeat those words

back to me.” (Repeat up to five times, but score only the first trial.)

Naming
“What is this?” (Point to a pencil or pen.)

(continued )

168 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

RECORDING YOUR FINDINGS

These findings suggest depression.

E X A M P L E S O F A B N O R M A L I T I E S

Recording Behavior and Mental Status

“Mental Status: The patient is alert, well-groomed, and cheerful. Speech is fluent
and words are clear. Thought processes are coherent, insight is good. The

patient is oriented to person, place, and time. Serial 7s accurate; recent and

remote memory intact. Calculations intact.”

OR
“Mental Status: The patient appears sad and fatigued; clothes are wrinkled.
Speech is slow and words are mumbled. Thought processes are coherent, but

insight into current life reverses is limited. The patient is oriented to person,

place, and time. Digit span, serial 7s, and calculations accurate, but responses

delayed. Clock drawing is good.”

Recording Your Findings

Reading
“Please read this and do what it says.” (Show examinee the words on the

stimulus form.)

CLOSE YOUR EYES

Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc.,

16204 North Florida Avenue, Lutz, Florida 33549, from the Mini Mental State Examination, by

Marshal Folstein and Susan Folstein, Copyright 1975, 1998, 2001 by Mini Mental LLC, Inc.

Published 2001 by Psychological Assessment Resources, Inc. Further reproduction is

prohibited without permission of PAR, Inc. The MMSE can be purchased from PAR, Inc. by

calling (813) 968-3003.

MMSE Sample Items (continued )

C H A P T E R 5 |

Behavior and Mental Status 169

Table 5-1 Somatic Symptom and Related Disorders

TYPES OF SOMATIC SYMPTOM AND RELATED DISORDERS

Type of Disorder Diagnostic Features

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

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

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

Psychological factors affecting other
medical conditions

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

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

Other Related Disorders or Behaviors

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

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

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

170 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

REFERENCES

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3. Substance Abuse and Mental Health Services Administration.
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13. Dwamena FC, Lyles JS, Frankel RM, et al. In their own words:
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25. Spitzer RL, Kroenke K, Williams JB, et al. Validation and utility of
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31. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for
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32. Kroenke K, Spitzer RL, Williams JB, et al. Anxiety disorders in
primary care: prevalence, impairment, comorbidity, and detection.
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33. Lowe B, Grafe K, Zipfel S, et al. Detecting panic disorder in medical
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som Res. 2003;55:515.

34. Conradt M, Cavanagh M, Franklin J, et al. Dimensionality of the
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35. Pilowsky U. Dimensions of hypochondriasis. Br J Psychiatry.
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36. Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new proce-
dure for diagnosing mental disorders in primary care. The PRIME-
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37. Compton WM, Thomas YF, Stinson FS, et al. Prevalence, correlates,
disability, and comorbidity of DSM-IV drug abuse and dependence
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Behavior and Mental Status 171

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survey on alcohol and related conditions. Arch Gen Psychiatry.
2007;64:566–576.

38. Gross R, Olfson M, Gameroff M, et al. Borderline personality dis-
order in primary care. Arch Int Med. 2002;162:50.

39. Grant BF, Chou SP, Goldstein RB, et al. Prevalence, correlates, dis-
ability, and comorbidity of DSM-IV borderline personality disor-
der: results from the Wave 2 National Epidemiologic Survey on
Alcohol and Related Conditions. J Clin Psychiatry. 2008;69:533.

40. Gunderson JG. Borderline personality disorder. N Engl J Med.
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41. Substance Abuse and Mental Health Services Administration, Cen-
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Substance Abuse and Mental Health Services Administration;
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NSDUH14–0904/NSDUH14–0904.pdf.

42. National Institutes of Mental Health. Any Mental Illness (AMI)
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43. National Institutes of Mental Health. Any Mood Disorder Among
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44. Gavin NI, Gaynes BN, Lohr KN, et al. Perinatal depression: a sys-
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45. Kroenke K, Spitzer RL, Williams JB. The Patient Health Question-
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46. Li Z, Page A, Martin G, et al. Attributable risk of psychiatric and
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50. LeFevre ML. Screening for suicide risk in adolescents, adults, and
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52. Mack KA. Drug-induced deaths—United States, 1999–2010.
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53. Moyer VA. Screening and behavioral counseling interventions in
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55. Strub RL, Black FW. The Mental Status Examination in Neurology.
2nd ed. Philadelphia, PA: FA Davis, 1985.

C H A P T E R 6 |

The Skin, Hair, and Nails 173

In this edition, you will find a helpful new approach to examining the skin, hair,
and nails and many new tables and photographs. This approach features careful
history taking; thorough inspection and palpation of benign and suspicious
lesions to better detect the three major skin cancers—basal cell carcinoma (BCC),
squamous cell carcinoma (SCC), and melanoma; focused techniques for assessing
changes in the hair and nails; accurate use of terminology to describe your find-
ings; and visual familiarity with important common benign and malignant skin
conditions. Updated information on skin cancer prevention and screening is
found in the section on Health Promotion and Counseling.

C H A P T E R

6
The Skin, Hair, and Nails

The Bates’ suite offers these additional resources to enhance learning and facilitate
understanding of this chapter:
■ Bates’ Pocket Guide to Physical Examination and History Taking, 8th edition
■ Bates’ Visual Guide to Physical Examination (Vol. 6: Skin)
â–  thePoint online resources, for students and instructors: http://thepoint.lww.com

Turn to Chapter 20, The Older Adult,

pp. 955–1008, to review skin changes

with aging.

Anatomy and Physiology
The skin keeps the body in homeostasis despite daily assaults from the environ-
ment. It retains body fluids while protecting underlying tissues from microor-
ganisms, harmful substances, and radiation. It modulates body temperature and
synthesizes vitamin D. Hair, nails, and sebaceous and sweat glands are consid-
ered appendages of the skin. The skin and its appendages undergo many
changes during aging.

Skin

The skin is the heaviest single organ of the body, accounting for approximately
16% of body weight and covering an area of roughly 1.2 to 2.3/m2. It contains
three layers: the epidermis, the dermis, and the subcutaneous tissues.

The most superficial layer, the epidermis, is thin avascular keratinized epithelium
consisting of two layers: an outer horny stratum corneum of dead keratinized
cells; and an inner cellular layer, the stratum basale and the stratum spinosum, also
known as the malpighian layer, where both melanin and keratin are formed.
Migration from the inner to the outer layer takes approximately 1 month.

174 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

ANATOMY AND PHYSIOLOGY

The epidermis depends on the underlying vascularized dermis for nutrition. The
dermis is a dense layer of interconnecting collagen and elastic fibers containing
sebaceous glands, sweat glands, hair follicles, and most of the terminals of the
cutaneous nerves (Fig. 6-1). Inferiorly, the dermis merges with subcutaneous fatty
tissue, or adipose tissue.

Normal skin color depends on the amount and type of melanin, but is also influ-
enced by underlying vascular structures, changing hemodynamics, and changes
in carotene and bilirubin. The amount of melanin, a brownish pigment, is genet-
ically determined and increased by exposure to sunlight. Hemoglobin in the red
blood cells transports oxygen in the form of oxyhemoglobin, a bright red pigment
in the arteries and capillaries that causes reddening of the skin. After passing
through the capillary bed and releasing oxygen to the tissues, the darker bluer
pigment of deoxyhemoglobin circulates in the veins. The scattering of light through
the turbid superficial layers of the skin or blood vessels also makes the veins look
bluer and less red than circulating venous blood.

Carotene, a yellow pigment, is found in the subcutaneous fat and heavily keratin-
ized areas such as the palms and soles. Bilirubin, a yellow-brown pigment, arises
from the breakdown of heme in the red blood cells.

Hair

Adults have two types of hair: vellus hair, which is short, fine, inconspicuous, and
relatively unpigmented; and terminal hair, which is coarser, thicker, more
conspicuous, and usually pigmented. Scalp hair and eyebrows are examples of
terminal hair.

Hair shaft

Horny layer
Cellular layer

Sebaceous
gland

Muscle that
erects hair shaft

Sweat gland

Hair follicle

Vein

Nerve

Artery

Duct of
sweat gland

Epidermis

Dermis

Subcutaneous
(adipose) tissue

Deep fascia

Skeletal muscle

Afferent nerve
endings

Vascular and lymphatic
capillary beds in

superficial dermis

F I G U R E 6 – 1 . Anatomy of the skin.

Pallor indicates anemia.

Cyanosis, a blue color, can indicate

decreased oxygen in the blood or

decreased blood flow in response

to a cold environment.

Jaundice, or yellowing of the skin,

results from increased bilirubin.

E X A M P L E S O F A B N O R M A L I T I E S

C H A P T E R 6 |

The Skin, Hair, and Nails 175

THE HEALTH HISTORY

Nails

Nails protect the distal ends of the fingers and toes. The firm rectangular and
usually curving nail plate gets its pink color from the vascular nail bed to which
the plate is firmly attached (Figs. 6-2 and 6-3). Note the whitish moon, or lunula,
and the free edge of the nail plate. Roughly one-fourth of the nail plate, the nail
root, is covered by the proximal nail fold. The cuticle extends from the fold and,
functioning as a seal, protects the space between the fold and the plate from
external moisture. Lateral nail folds cover the sides of the nail plate. Note that the
angle between the proximal nail fold and nail plate is normally less than 180°.

Fingernails grow approximately 0.1 mm daily; toenails grow more slowly.

Sebaceous Glands and Sweat Glands

Sebaceous glands produce a fatty substance secreted onto the skin surface through the
hair follicles. These glands are present on all skin surfaces except the palms and soles.

Sweat glands are of two types: eccrine and apocrine. The eccrine glands are widely
distributed, open directly onto the skin surface, and by their sweat production
help to control body temperature. In contrast, the apocrine glands are found
chiefly in the axillary and genital regions and usually open into hair follicles.
Bacterial decomposition of apocrine sweat is responsible for adult body odor.

Lateral
nail fold Lunula

Proximal
nail fold

Nail plate CuticleFree edge

F I G U R E 6 – 2 . Anatomy of the

fingernail.

Nail rootProximal nail fold

Nail plate

Cross section
of nail plate Nail bed Distal phalanx

F I G U R E 6 – 3 . Cross-section of

fingernail.

Common or Concerning Symptoms

● Growths
● Rashes
● Hair loss or nail changes

Growths. Start by asking if the patient is concerned about any new growths
or rashes: “Have you noticed any changes in your skin? … your hair? … your
nails?” “Have you had any rashes? … sores? … lumps? … itching?” If the patient
reports a new growth, it is important to pursue the patient’s personal and family
history of skin cancer. Note the type, location, and date of any past skin cancer
and ask about regular self-skin examination and use of sunscreen. Also ask “Has
anyone in your family had a skin cancer removed? If so, who? Do you know what
type of skin cancer—basal cell carcinoma, squamous cell carcinoma, or
melanoma?” Document the response even if the patient does not know which
type and counsel the patient about skin cancer prevention.

Rashes. For complaints of rash, ask about itching, the most important
symptom when assessing rashes. Does itching precede the rash or follow the
rash? For itchy rashes, ask about seasonal allergies with itching and watery eyes,
asthma, and atopic dermatitis, often accompanied by rash on the inside of the
elbows and knees in childhood. Can the patient sleep all night or does itching
wake up the patient? For rashes, it is important to find out what type of
moisturizer or over-the-counter products have been applied.

See discussion of prevention in Health

Promotion and Counseling section,

pp. 176–180.

Causes of generalized itching, without

apparent rash, include dry skin; preg-

nancy; uremia; jaundice; lymphomas

and leukemia; drug reactions; and,

less commonly, polycythemia vera and
thyroid disease.

E X A M P L E S O F A B N O R M A L I T I E S

The Health History

176 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

HEALTH PROMOTION AND COUNSELING

Also, ask about dry skin, which can cause itching and rash, especially in children
with atopic dermatitis and older adults, due to loss of the natural moisture bar-
rier in the epidermis.

Hair Loss or Nail Changes. Patients often report hair loss or nail changes
spontaneously. For hair loss, ask if there is hair thinning or hair shedding and, if
so, where. If shedding, does the hair come out at the roots or break along the hair
shafts? Ask about hair care practices like frequency of shampooing and use of
dyes, chemical relaxers, or heating appliances. See Table 6-11, pp. 209–210, for
normal patterns of hair loss in men and women and counsel affected patients
appropriately. Be familiar with common nail changes such as onychomycosis,
habit tic deformity, and melanonychia, shown in Table 6-12, pp. 211–212.

Encourage use of moisturizers to

replace the lost moisture barrier.

Some recommended brands even

include sunscreen.1,2

The most common causes of diffuse

hair thinning are male and female

pattern baldness.

Hair shedding at the roots is common in

telogen affluvium and alopecia areata.

Hair breaks along the shaft suggest

damage from hair care or tinea capitis.

Important Topics for Health Promotion
and Counseling

● Skin cancer prevention
● Skin cancer screening

Skin Cancer Prevention. Clinicians play a vital role in educating patients
about skin cancer prevention. Skin cancers are the most common cancers in the
United States, affecting an estimated one in five Americans during their lifetime.3 They
are caused by a combination of genetic predisposition and ultraviolet radiation
exposure. Fair-skinned individuals are at highest risk. The most common skin cancer
is basal cell carcinoma (BCC), followed by squamous cell carcinoma (SCC), and melanoma.

Melanoma. Although it is the least common skin cancer, melanoma is the
most lethal due to its high rate of metastasis and high mortality at advanced
stages, causing over 70% of skin cancer deaths.4 The incidence of melanoma has
more than doubled in the past three decades, the most rapid increase of any
cancer.5 Melanoma is now the fifth most frequently diagnosed cancer in men and
the seventh most frequently diagnosed in women. In the United States in 2014,
the estimated lifetime risk was 1 in 48 for whites (2%), 1 in 200 for Hispanics,
and 1 in 1,000 for African Americans.6

Ask patients about the melanoma risk factors listed below, and use of the Mela-
noma Risk Assessment Tool developed by the National Cancer Institute, available
at http://www.cancer.gov/melanomarisktool/. This tool assesses an individual’s
5-year risk of developing melanoma based on geographic location, gender, race,
age, history of blistering sunburns, complexion, number and size of moles,
freckling, and sun damage. It is applicable up to age 70 years, but is not intended
for patients with a family history of melanoma.

For discussion and examples of types

of skin cancers, turn to the tables on

pp. 197–203.

E X A M P L E S O F A B N O R M A L I T I E S

Health Promotion and
Counseling: Evidence and
Recommendations

C H A P T E R 6 |

The Skin, Hair, and Nails 177

HEALTH PROMOTION AND COUNSELING

Avoiding Ultraviolet Radiation and Tanning Beds. Increasing life-
time sun exposure correlates directly with increasing risk of skin cancer. Inter-
mittent sun exposure appears to be more harmful than chronic exposure.9 The
best defense against skin cancers is to avoid ultraviolet radiation exposure by
limiting time in the sun, avoiding midday sun, using sunscreen, and wearing
sun-protective clothing with long sleeves and hats with wide brims. Advise
patients to avoid indoor tanning, especially children, teens, and young adults.
Use of indoor tanning beds, especially before age 35 years, increases risk of
melanoma by as much as 75%.

In 2009, the International Agency for Research on Cancer classified ultraviolet-
emitting tanning devices as “carcinogenic to humans.”10 Options for tanning
include self-tanning products or sprays in conjunction with sunscreen. Targeted
patient messages in primary care practices have been shown to amplify these
sun-protective behaviors.11,12 The U.S. Preventive Services Task Force (USP-
STF) has made a grade B recommendation supporting behavioral counseling
through minimizing ultraviolet radiation exposure in fair-skinned children,
adolescents, and young adults aged 10 to 24 years and cites insufficient evi-
dence, grade I, for counseling adults older than 24 years, but noted no harms
associated with counseling.13

Regular Use of Sunscreen Prevents Skin Cancer. There are many
myths about sunscreen. A landmark study in 2011 demonstrated that the regu-
lar use of sunscreen decreases the incidence of melanoma.14 This well-designed
study showed that when clinicians strongly encouraged use of sunscreen,
patients were more likely to use it regularly and melanoma incidence declined.

Advise patients to use at least sun protective factor (SPF) 30 and broad-spectrum
protection (Fig. 6-4). For water exposure, patients should use water-resistant
sunscreens. New U.S. Food and Drug Administration labeling guidelines in 2011
make it easy to see these features on all bottles of sunscreen. Free information
about protection and proper use of sunscreen are available from the AAD and the
Skin Cancer Foundation.15,16

Risk Factors for Melanoma

● Personal or family history of previous melanoma4,7–9

● ≥50 common moles
● Atypical or large moles, especially if dysplastic
● Red or light hair
● Solar lentigines (acquired brown macules on sun-exposed areas)
● Freckles (inherited brown macules)
● Ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths
● Light eye or skin color, especially skin that freckles or burns easily
● Severe blistering sunburns in childhood
● Immunosuppression from human immunodeficiency virus (HIV) or from

chemotherapy
● Personal history of nonmelanoma skin cancer

Signs of chronic sun damage include

numerous solar lentigines on the
shoulders and upper back, many

melanocytic nevi, solar elastosis
(yellow, thickened skin with bumps,

wrinkles, or furrowing), cutis rhomboi-
dalis nuchae (leathery thickened skin
on the posterior neck), and actinic
purpura. See Table 6-9, Signs of Sun
Damage, on p. 206.

Sun
Screen

SPF 30
Broad Spectrum

Water Resistant Water Resistant

Broad Spectrum

SPF 30 or Higher

F I G U R E 6 – 4 . Advise use of broad

spectrum sunscreen with SPF 30.

E X A M P L E S O F A B N O R M A L I T I E S

178 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

HEALTH PROMOTION AND COUNSELING

Skin Cancer Screening. Although the USPSTF found insufficient
evidence (grade I) to recommend routine skin cancer screening by primary care
physicians, it does advise clinicians to “remain alert for skin lesions with
malignant features” during routine physical examinations and reference the
ABCDE criteria.17,18 The American Cancer Society (ACS) and the AAD
recommend full-body examinations for patients over age 50 years or at high risk,
because melanoma can appear in any location.15,19 High-risk patients are those
with a personal or family history of multiple or dysplastic nevi or previous
melanoma. Patients who have a clinical skin examination within the 3 years
prior to a melanoma diagnosis have thinner melanomas than those who did
not have a clinical skin examination.20 Both new and changing nevi should be
closely examined, as at least half of melanomas arise de novo from isolated
melanocytes rather than pre-existing nevi. Also consider “opportunistic
screening” as part of the complete physical examination for patients with
significant sun exposure and patients over age 50 years without prior skin
examination or who live alone.

Since the USPSTF review, an important German study of over 350,000 patients
reported that full-body primary care screening with dermatology referrals for
concerning lesions reduced melanoma mortality by more than 47%.21 Survival
from melanoma strongly correlates with tumor thickness. Two further studies
demonstrate that patients receiving skin examinations are more likely to have
thinner melanomas.20,22

Detecting melanoma requires practice and knowledge of how benign nevi
change over time, often going from flat to raised or acquiring additional brown
pigment. Studies have shown that even limited clinician training makes a dif-
ference in detection: patients of primary care providers who spent 1.5 hours
completing an online tutorial improved diagnostic accuracy. Similar studies
show such training results in thinner melanomas than patients of providers
without such training.23–26

Screening for Melanoma: The ABCDEs. Clinicians should apply the
ABCE-EFG method when screening moles for melanoma (this does not apply
for non-melanocytic lesions like seborrheic keratoses). The sensitivity of this
tool for detecting melanoma ranges from 43% to 97%, and specificity ranges
from 36% to 100%; diagnostic accuracy depends on how many criteria are used
to define abnormality.27 If two or more of these features are present, biopsy
should be considered. The most sensitive is E, for evolution or change. Pay close
attention to nevi that have changed rapidly based on objective evidence.

Turn to Tables 6-4 through 6-6 on

pp. 197–203 showing rough, pink,

and brown nevi and their mimics.

The ABCDE Rule

The ABCDE method has been used for many years to teach clinicians and

patients about features suspicious for melanoma. If two or more of these are

present, risk of melanoma increases and biopsy should be considered. Some

have suggested adding EFG to help detect aggressive nodular melanomas.

(continued )

Review the ABCDE-EFG rule and pho-

tographs in Table 6-6, pp. 200–203,

which provide additional helpful

identifiers and comparisons of benign

brown lesions with melanoma.

E X A M P L E S O F A B N O R M A L I T I E S

C H A P T E R 6 |

The Skin, Hair, and Nails 179

HEALTH PROMOTION AND COUNSELING

The ABCDE Rule (continued )

Melanoma Benign Nevus

Asymmetry
Of one side of mole

compared to the

other

Border irregularity
Especially if ragged,

notched, or blurred

Color variations
More than two colors,

especially blue-black,

white (loss of pigment

due to regression), or

red (inflammatory

reaction to abnormal

cells)

Diameter >6 mm
Approximately the

size of a pencil eraser

(continued )

E X A M P L E S O F A B N O R M A L I T I E S

With the exception of a homogenous

blue color in a blue nevus, blue or

black color within a larger pigmented

lesion is especially concerning for

melanoma.

Early melanomas may be <6 mm, and
many benign lesions are >6 mm.

180 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

TECHNIQUES OF EXAMINATION

Techniques of Examination

The ABCDE Rule (continued )

Melanoma Benign Nevus

Evolving
Or changing rapidly in

size, symptoms, or

morphology

● Elevated
● Firm to palpation
● Growing progressively over several weeks

Patient Screening: The Self Skin Examination. The AAD and the
ACS recommend regular self-skin examination based on expert opinion.15,28

Instruct patients with risk factors for skin cancer and melanoma, especially
those with a history of high sun exposure, prior or family history of melanoma,
and ≥50 moles or >5 to 10 atypical moles, to perform regular self-skin exami-
nations. Patients who examine their skin regularly are more likely to have
thinner melanomas, if detected.24,29 Teach patients about the appearance of
different skin cancers, making use of the excellent resources available on the
internet.15

See Patient Instructions for Self Skin

Examination, pp. 187–188.

Approximately half of melanomas are

initially detected by patients or their

partners.

See Tables 6-1 and 6-2 for examples

and descriptions of primary skin

lesions including flat, raised, fluid-

filled, pustules, furuncles, nodules,

cysts, wheals, and burrows (pp. 191–

195); Table 6-3 for a safari of benign

lesions (p. 196); and Tables 6-4 to 6-6

for rough, pink, and brown lesions

and their mimics (pp. 197–203).

E X A M P L E S O F A B N O R M A L I T I E S

Evolution, or change, is the most sen-

sitive of these criteria. A reliable his-

tory of change may prompt biopsy of

a benign-appearing lesion.

Full-Body and Integrated Skin Examinations

Perform a full-body skin examination in the context of the overall physical exami-
nation. Some patients at risk for melanoma, especially men over age 50 years,
may not request this examination, so the general physical examination is an
important opportunity to look for melanomas and other skin cancers, especially
in areas patients find hard to see such as the back and posterior legs.

Inspect and palpate all skin lesions, focusing on key features that help dis-
tinguish if lesions are benign or suspicious for malignancy. Are they raised,
flat, or fluid-filled? 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 specified below. Changing moles, a
history of skin cancer, and other risk factors all warrant a full-body skin
examination.

C H A P T E R 6 |

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TECHNIQUES OF EXAMINATION

Even during routine examinations, you can pursue an integrated skin examination
as you examine sun-exposed areas that are already easily accessible.

â–  When examining the head and neck, remember to inspect closely for skin
cancers as well as common benign lesions such as acne, which can become
scarring.

â–  Look at the arms and hands for sun damage, actinic keratoses, and SCCs, as
well as normal findings. Educate the patient about such findings as solar
lentigines and seborrheic keratoses.

â–  When listening to the lungs, remove the shirt or open the gown and fully
inspect the back for normal moles versus possible melanomas. Think about
this approach throughout the physical examination. Note any vascular or
purpuric lesions, petechiae, or eccymoses.

Integrating the skin examination into the physical examination and routinely
recording your findings as part of the general write-up saves time and contrib-
utes to earlier detection of skin cancers, when they are easier to treat. Begin
implementing this approach early in your training on each patient you examine,
whether outpatient or inpatient. Instead of documenting what is not present on
the skin, document what is present. This is the best way to learn to distinguish
normal skin lesions from abnormal lesions and potential skin cancers. Systemic
illnesses also have many associated skin findings.

Preparing for the Examination

Lighting, Equipment, and Dermoscopy. Make sure there is
adequate lighting. Good overhead ambient lighting or natural light from
windows is usually adequate. You may wish to add a strong light source if the
room is dark.

You will also need a small ruler or tape measure; these can often be obtained
from packets containing disposable marking pens. In addition, a small mag-
nifying glass allows you to examine lesions more closely. These tools help you
document important features of skin lesions, such as size, shape, color, and
texture.

Dermoscopy is an increasingly useful office practice for deciding whether a
melanocytic lesion is benign or malignant. This handheld device provides
cross-polarized or unpolarized light to visualize patterns of pigmentation or
vascular structures. With adequate clinician training, use of dermoscopy
improves the sensitivity and specificity of differentiating melanomas from
benign lesions.24,30

See Tables 6-7, Acne Vulgaris: Primary

and Secondary Lesions, p. 204.

See Table 6-9, Signs of Sun Damage,

p. 206.

See Risk Factors for Melanoma

on p. 177.

See Table 6-10, Systemic Illnesses and

Associated Skin Findings, pp. 207–208.

E X A M P L E S O F A B N O R M A L I T I E S

See Table 6-8, Vascular and Purpuric

Lesions of the Skin, p. 205.

182 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

TECHNIQUES OF EXAMINATION

The Patient Gown. Ask the
patient to change into a gown with
the opening in the back and clothes
removed except for underwear (Fig.
6-5). This is the first requirement for
the skin examination. Ask if the
patient would like to have a chaperone
present, especially when examination
of the genital areas is anticipated.

Handwashing. Before beginning the examination, cleanse your hands
thoroughly. It is important for you to palpate lesions for texture, firmness, and
scaliness. Because frequent handwashing increases the risk of irritant contact
dermatitis, dermatologists recommend using hand sanitizers, which are less
drying than soap and water. Explain that cleansing your hands ensures
hygiene and an optimal examination. It is best to restrict use of gloves to
touching wounds rather than throughout the examination so that the patient
feels accepted. The power of professional and caring human touch can be
therapeutic, especially for patients with stigmatizing diseases like psoriasis
and HIV.

The Skin Examination

Important Terms for Describing Skin Lesions. It is important to
use specific terminology to describe skin lesions and rashes. Good descriptions
include each of the following elements: number, size, color, shape, texture,
primary lesion, location, and configuration.

For example, for seborrheic keratosis, examine and record: “Multiple 5 mm to
2 cm tan to brown oval stuck-on flat-topped verrucous plaques on the back and
abdomen, following skin tension lines.” Note the description of each element:
number, multiple; size, 5 mm–2 cm; color, tan to brown; shape, oval; texture, flat-
topped verrucous; location, on the back and abdomen; and configuration, follow-
ing skin tension lines.

F I G U R E 6 – 5 . The patient gown

should open in the back.

Describing Skin Findings

● Primary lesion: Primary lesions are flat or raised.
● Flat: You cannot palpate the lesion with your eyes closed.

● Macule: Lesion is flat and <1 cm.
● Patch: Lesion is flat and >1 cm.

● Raised: You can palpate the lesion with eyes closed.
● Papule: Lesion is raised, <1 cm, and not fluid filled.
● Plaque: Lesion is raised, >1 cm, but not fluid filled.

See Table 6-1, Describing Primary Skin

Lesions: Flat, Raised, and Fluid-filled,

pp. 191–193; Table 6-2, Additional

Primary Lesions: Pustules, Furuncles,

Nodules, Cysts, Wheals, Burrows,

pp. 194–195; and Table 6-3, Dermatol-

ogy Safari: Benign Skin Lesions,

p. 196.

E X A M P L E S O F A B N O R M A L I T I E S

(continued )

C H A P T E R 6 |

The Skin, Hair, and Nails 183

TECHNIQUES OF EXAMINATION

Describing Skin Findings (continued )

● Vesicle: Lesion is raised, <1 cm, and filled with fluid.
● Bulla: Lesion is raised, >1 cm, and fluid filled.

● Other primary lesions include erosions, ulcers, nodules, ecchymoses,

petechiae, and palpable purpura.

● Number: Lesions can be solitary or multiple. If multiple, record how many. Also
consider estimating the total number of the type of lesion you are describing.

● Size: Measure with a ruler in millimeters or centimeters. For oval lesions,
measure in the long axis, then perpendicular to the axis.

● Shape: Some good words to learn are “circular,” “oval,” “annular” (ring-like,
with central clearing), “nummular” (coin-like, no central clearing), and

“polygonal.”

● Color: Use your imagination and be creative. Refer to a color wheel, if needed.
There are many shades of tan and brown, but start with tan, light brown, and

dark brown if you are having trouble.

● Use “skin-colored” to describe a lesion that is the same shade as the

patient’s skin.

● For red lesions or rashes, blanch the lesion by pressing it firmly with your

finger or a glass slide to see if the redness temporarily lightens then refills.

● Texture: Palpate the lesion to see if it is smooth, fleshy, verrucous or warty, or
scaly (fine, keratotic, or greasy scale).

● Location: Be as specific as possible. For single lesions, measure their distance
from other landmarks (e.g., 1 cm lateral to left oral commissure).

● Configuration: Although not always necessary, describing patterns is often
very helpful.

For more information and additional illustrations of each of these elements,

LearnDerm is a free and very helpful website.31

Examples are herpes zoster with unilateral
and dermatomal vesicles; herpes simplex,
with grouped vesicles or pustules on an

erythematous base; tinea pedis with
annular lesions; and poison ivy allergic
contact dermatitis with linear lesions.

Blanching lesions are erythematous
and suggest inflammation. Non-

blanching lesions such as petechiae,

purpura, and vascular structures

(cherry angiomas, vascular malforma-

tions) are not erythematous, but rather

bright red, purple, or violaceous. See

Table 6-8, Vascular and Purpuric

Lesions of the Skin, p. 205.

Scaling can be greasy, like sebor-
rheic dermatitis or seborrheic kerato-
ses, dry and fine like tinea pedis,
or hard and keratotic like actinic
keratoses or SCC.

Techniques of Examination—Patient Seated. Choose one of two
patient positions for performing the full-body skin examination. The patient can
be seated or can 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.

E X A M P L E S O F A B N O R M A L I T I E S

184 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

TECHNIQUES OF EXAMINATION

With the patient seated on the examining table, stand in front of the patient and
adjust the table to a comfortable height. Start by examining the hair and scalp
(Fig. 6-6). Separate the hair to examine the scalp from one side to the other. You
may need to use your fingers or a cotton-tipped applicator (“Q-tip”) to separate
the hair to see the scalp (Fig. 6-7). Note the distribution, texture, and quantity
of hair. Remember to inspect the ears.

Now inspect the head and neck, including the forehead; eyes including eyelids,
conjunctivae, sclerae, eyelashes, and eyebrows; nose, cheeks, lips, oral cavity,
and chin; and anterior neck (Figs. 6-8 to 6-10).

Alopecia, or hair loss, can be diffuse,
patchy, or total. Male and female pat-

tern hair loss are normal with aging.

Focal patches may be lost suddenly in

alopecia areata. Refer scarring alope-
cia to a dermatologist.

Sparse hair is seen in hypothyroidism;

fine, silky hair in hyperthyroidism. See

Table 6-11, Hair Loss, pp. 209–210.

F I G U R E 6 – 6 . Part the hair on

the scalp.

F I G U R E 6 – 7 . Use fingers or

an applicator to better visualize

the scalp.

Look for signs of BCC on the face. See

Table 6-5, Pink Lesions: Basal Cell

Carcinoma and Its Mimics, pp. 198–199.

F I G U R E 6 – 8 . Inspect

the forehead.

F I G U R E 6 – 9 . Inspect

the face, eyes, and ears.

F I G U R E 6 – 1 0 . Inspect

the anterior neck.

Move the gown to see each area. Ask permission first
by saying, “I’d like to separate the gown to look at
your back now. Is that okay?” (Fig. 6-11). Do this for
every part of the body.

F I G U R E 6 – 1 1 . Inspect

the back.

E X A M P L E S O F A B N O R M A L I T I E S

C H A P T E R 6 |

The Skin, Hair, and Nails 185

TECHNIQUES OF EXAMINATION

Now inspect the shoulders, arms, and hands (Fig. 6-12). Inspect and palpate the
fingernails (Fig. 6-13). Note their color, shape, and any lesions. Longitudinal
bands of pigment are normal in people with darker skin.

See Table 6-12, Findings In or Near the

Nails, pp. 211–212.

F I G U R E 6 – 1 2 . Inspect the arms. F I G U R E 6 – 1 3 . Inspect and palpate

the fingernails.

F I G U R E 6 – 1 4 . Inspect the chest. F I G U R E 6 – 1 5 . Inspect the abdomen.

Now inspect the chest and abdomen (Fig. 6-14), preparing the patient by saying,
“Let’s look at your upper chest and then your stomach area.” The patient will
generally help by lowering or raising the gown to expose these areas and cover-
ing up when you are finished (Fig. 6-15).

Now let the patient know that you will be inspecting the thighs and lower legs
(Fig. 6-16). You and the patient can work together to expose the skin in these
areas, moving down to the feet and toes (Fig. 6-17). Inspect and palpate the
toenails, and inspect the soles and between the toes (Figs. 6-18 and 6-19).

F I G U R E 6 – 1 6 . Inspect the thighs. F I G U R E 6 – 1 7 . Inspect the lower legs.

E X A M P L E S O F A B N O R M A L I T I E S

186 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

TECHNIQUES OF EXAMINATION

Now ask the patient to stand so that you inspect the lower back and posterior legs
(Figs. 6-20 and 6-21). If needed, ask the patient to uncover the buttocks
(Fig. 6-22). Examination of the breasts and genitalia may be saved for last. These
examinations are described in other chapters. Remember to consider patient
comfort, modesty, and use of a chaperone during these examinations.

F I G U R E 6 – 1 8 . Inspect the soles of

the feet.

F I G U R E 6 – 1 9 . Inspect between the

toes.

Techniques of Examination—Patient Supine and Prone. Some
clinicians prefer this positioning for more thorough examinations, although
patients may feel it is more “clinical.” Practice and feedback from patients will
give you a sense of patient preferences.

Start with the patient supine, lying flat on the examination table. As with the
seated position, start by inspecting the scalp, face, and anterior neck (Fig. 6-23).
Next, move to the shoulders, arms, and hands (Fig. 6-24); then to the chest and

F I G U R E 6 – 2 0 . Inspect

the back.

F I G U R E 6 – 2 1 . Inspect

the posterior legs.

F I G U R E 6 – 2 2 . Inspect

the buttocks.

See Chapter 10, Breasts and Axillae,

pp. 419–447; Chapter 13, Male Genita-

lia, pp. 541–563; and Chapter 14,

Female Genitalia, pp. 565–606.

F I G U R E 6 – 2 3 . Inspect the scalp. F I G U R E 6 – 2 4 . Inspect the hands.

E X A M P L E S O F A B N O R M A L I T I E S

C H A P T E R 6 |

The Skin, Hair, and Nails 187

TECHNIQUES OF EXAMINATION

F I G U R E 6 – 2 5 . Inspect the chest. F I G U R E 6 – 2 6 . Inspect the anterior

thighs.

abdomen (Fig. 6-25); anterior thighs (Fig. 6-26); and lower legs, feet, and, if appro-
priate, the genitalia. As noted previously, ask permission when moving the gown
to expose different areas, and let the patient know which areas you will be exam-
ining next so the patient feels more involved in the examination.

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

Special Techniques

Patient Instructions for the Self Skin-Examination. The AAD
recommends regular self-examination of the skin using the techniques illustrated.
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 to identify melanomas by looking at photographs of benign and
malignant nevi on easy-to-access websites, handouts, or tables in this chapter.

Review the ABCDE-EFG criteria

on pp. 178–180.

Patient Instructions for Skin
Self-Examination

Examine your body front and back in

the mirror, then look at your right

and left sides with arms raised.

Bend elbows and look carefully at

forearms, upper underarms, and

palms.
(continued )

E X A M P L E S O F A B N O R M A L I T I E S

188 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

TECHNIQUES OF EXAMINATION

Examining the Patient with Hair
Loss. Based on the patient’s history, start
by examining the hair to determine the over-
all pattern of hair loss or hair thinning.32
Inspect the scalp for erythema, scaling, pus-
tules, tenderness, bogginess, and scarring.
Look at the width of the hair part in various
sections of the scalp. To examine the hair for
shedding from the roots, perform a hair pull
test by gently grasping 50 to 60 hairs with
your thumb and index and middle fingers,
pulling firmly away from the scalp (Fig.
6-27). If all the hairs have telogen bulbs, the
most likely diagnosis is telogen effluvium. To
examine the hair for fragility, perform the tug
test by holding a group of hairs in one hand,
pulling along the hair shafts with the other
(Fig. 6-28); if any hairs break, it is abnormal.

Patient Instructions for Skin
Self-Examination (continued )

Look at the backs of your legs and

feet, the spaces between your toes,

and the soles.

Examine the back of your neck and

scalp with a hand mirror. Part hair for

a closer look.

Finally, check your back and buttocks

with a hand mirror.

Source: Adapted from American Academy of Dermatology. How to perform a self-exam. Available at

https://www.aad.org/spot-skin-cancer/understanding-skin-cancer/how-do-i-check-my-skin/how-to-

perform-a-self-exam. Accessed February 12, 2015.

F I G U R E 6 – 2 7 . Hair pull test.

F I G U R E 6 – 2 8 . Tug test.

C H A P T E R 6 |

The Skin, Hair, and Nails 189

RECORDING YOUR FINDINGS

Most (97%) hair loss is nonscarring, but any scarring, namely shiny spots with-
out any hair follicles on close examination with a magnifying glass, should
prompt referral to dermatology for scalp biopsy.

Evaluating the Bedbound Patient. People confined to bed, especially
when they are emaciated, elderly, or neurologically impaired, are particularly
susceptible to skin damage and ulceration. Pressure sores result from sustained
compression that obliterates arteriolar and capillary blood flow to the skin, and
from shear forces created by body movements. When a person slides down in
bed from a partially sitting position, for example, or is dragged rather than lifted
up after being supine, rough movement can distort the soft tissues of the buttocks
and close off the arteries and arterioles. Friction and moisture further increase
the risk of abrasions and sores.

Assess every susceptible patient by carefully inspecting 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.

Possible internal causes of diffuse

nonscarring hair shedding in young

women are iron-deficiency anemia
and hyper- or hypothyroidism.

See Table 6-13, Pressure Ulcers, p. 213.

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.

For more details about this terminology,

turn to Techniques of Examination,

pp. 182–183.

E X A M P L E S O F A B N O R M A L I T I E S

Recording Your Findings
Note that initially you may use sentences to describe your findings; later you will
use phrases. The examples below contain phrases appropriate for most write-ups.

As stated on p. 182, use specific terms to describe skin lesions and rashes,
including:

■ Number—solitary or multiple; estimate of total number

■ Size—measured in millimeters or centimeters

■ Color—including erythematous if blanching; if nonblanching, vascular-like
cherry angiomas and vascular malformations, petechiae, or purpura

■ Shape—circular, oval, annular, nummular, or polygonal

■ Texture—smooth, fleshy, verrucous or warty, keratotic; greasy if scaling

■ Primary lesion—flat, a macule or patch; raised, a papule or plaque; or fluid
filled, a vesicle or bulla (may also be erosions, ulcers, nodules, ecchymoses,
petechiae, and palpable purpura)

■ Location—including measured distance from other landmarks

■ Configuration—grouped, annular, linear

190 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

RECORDING YOUR FINDINGS

Recording the Skin, Hair, and Nails
Physical Examination

“Skin warm and dry. Nails without clubbing or cyanosis. Approximately 20

brown, round macules on upper back, chest, and arms, are all symmetric in

pigmentation, none suspicious. No rash, petechiae, or ecchymoses.”

OR
“Marked facial pallor, and circumoral cyanosis. Palms cold and moist. Cyano-

sis in nail beds of fingers and toes. Numerous palpable purpura on lower legs

bilaterally.”

OR
“Scattered stuck-on verrucous plaques on back and abdomen. Over 30 small

round brown macules with symmetric pigmentation on back, chest, and arms.

Single 1.2 × 1.6 cm asymmetric dark brown and black plaque with erythematous,
uneven border, on left upper arm.”

OR
“Facial plethora. Skin icteric. Many telangiectatic mats on chest and abdomen.

Single 5 mm pearly papule with rolled border on left zygomatic cheek. Nails

with clubbing but no cyanosis.”

There are normal nevi and perfusion

without any rashes or suspicious

lesions.

These findings suggest central cyano-

sis and vasculitis.

These findings suggest normal sebor-

rheic keratoses and benign nevi, but

also a possible malignant melanoma.

These findings suggest probable end-

stage liver disease and incidental BCC.

E X A M P L E S O F A B N O R M A L I T I E S

C H A P T E R 6 |

The Skin, Hair, and Nails 191

Table 6-1 Describing Primary Skin Lesions: Flat,
Raised, and Fluid-Filled

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.

Flat Spots

If you run your finger over the lesion but do not feel the lesion, the lesion is flat. If a flat spot is small (<1 cm), it is a
macule. If a flat spot is larger (>1 cm), it is a patch.

Macules (flat, small)

Multiple 3–8-mm erythematous
confluent round macules on chest,
back, and arms; morbilliform drug
eruption

Multiple 2–5-mm hypopigmented, hyperpigmented, or tan round to oval macules on
upper neck and back, upper chest, and arms with slight inducible scale on scraping
(tinea versicolor)

Multiple scattered 2–4-mm round
and oval brown macules,
symmetrically pigmented, on back
and chest with reticular pattern on
dermoscopy; benign melanocytic nevi

Solitary 6-mm dark brown round symmetric
macule on upper back; benign melanocytic
nevus

Solitary dark brown, blue-gray, and red
7-mm macule with irregular borders
and fingerlike projections of pigment,
on right forearm; malignant melanoma

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

Bilateral erythematous, geographic
patches with peripheral scaling, on
inner thighs bilaterally, sparing the
scrotum; tinea cruris

(continued)

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Table 6-1 Describing Primary Skin Lesions: Flat,
Raised, and Fluid-Filled (Continued )

Raised Spots

If you run your finger over the lesion and it is palpable above the skin, it is raised. If a raised spot is small (<1 cm), it is a
papule. If a raised spot is larger (>1 cm), it is a plaque.

Papules (raised, small)

Solitary 7-mm oval pink pearly papule with
overlying telangiectasias on right nasojugal fold;
basal cell carcinoma

Multiple 2–4-mm soft, fleshy skin-colored to
light brown papules on lateral neck and axillae
in skin folds; skin tags

Multiple 3–5-mm pink firm smooth domed
papules with central umbillications, in mons
pubis, and on penile shaft; molluscum contagiosum

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

Bilateral erythematous, lichenified (thickened
from rubbing) poorly circumscribed plaques
on flexor wrists, antecubital fossae, and popli-
teal fossae; atopic dermatitis

Single, oval, flat-topped superficial
erythematous to skin-colored plaque on
right abdomen; herald patch of pityriasis
rosea

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Multiple round to oval scaling
violaceous plaques on abdomen and
back; pityriasis rosea

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

Fluid-filled Lesions

If the lesion is raised, filled with fluid, and small (<1 cm), it is a vesicle. If a fluid-filled spot is larger (>1 cm), it is a bulla.

Vesicles (fluid-filled, small)

Multiple 2–4-mm vesicles and
pustules on erythematous base,
grouped together on left neck; herpes
simplex virus

Grouped 2–5-mm vesicles on erythematous
base on left upper abdomen and trunk in a
dermatomal distribution that does not cross
the midline; herpes zoster or “shingles”

Scattered 2–5-mm erythematous papules
and vesicles with transudate crust, some
with linear arrays, on forearms, neck, and
abdomen; rhus dermatitis or allergic
contact dermatitis from poison ivy

Bullae (fluid-filled, large)

Solitary 8-cm dusky oval patch with
smaller inner violaceous patch and
central 3.5-cm tense bulla, on right
posterior lower back; bullous fixed drug
eruption

Several tense bullae on lower legs; insect bites Many vesicles and tense bullae up to
4 cm, some having unroofed and left large
(4-cm) erosions, on lower legs bilaterally
up to the line of the top of combat boots;
an inherited skin fragility disorder

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Table 6-2 Additional Primary Lesions: Pustules, Furuncles,
Nodules, Cysts, Wheals, Burrows

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

∼30 2–5-mm erythematous papules and
pustules on frontal, temporal, and parietal
scalp; bacterial folliculitis

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

Table 3.1 Motivational Interviewing: A Clinical Example

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Subcutaneous mass/cyst: Whether mobile or fixed, cysts are encapsulated collections of fluid or semisolid

Solitary 2-cm tethered subcutane-
ous cyst with overlying punctum
releasing caseous whitish yellow
substance with foul odor; epider-
mal inclusion cyst

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

Burrow: Small linear or serpiginous pathways in the
epidermis created by the scabies mite

Many variably sized (1–10-cm)
wheals on lateral neck, shoulders,
abdomen, arms, and legs; urticaria

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

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Table 6-3 Dermatology Safari: Benign Lesions

Practice makes perfect . . . Look for these common lesions during your clinical rotations. Perform a skin examination on as many
patients as you can. If you are unsure about identifying the lesion, ask your instructors or attending physicians for help.

Cherry angiomas Seborrheic keratosis Solar lentigines

Benign melanocytic nevi Dermatofibroma Keloids

Epidermal inclusion cyst Pilar cyst Lipoma

Table 3.1 Motivational Interviewing: A Clinical Example

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Table 6-4 Rough Lesions: Actinic Keratoses, Squamous
Cell Carcinoma, and Their Mimics

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. SCC most commonly arises on sun-damaged skin of the
head, neck, and dorsal arms and hands and can metastasize if left untreated. It consists of more mature cells usually resembling
the spinous layer of the epidermis and accounts for ∼16% of skin cancers. If left untreated, actinic keratoses progress to SCC at a
rate of about 1 in 1,000 per year. Counsel affected patients about sun avoidance and use of sunscreen and offer treatment to
prevent progression to SCC.

Actinic Keratosis and
Squamous Cell Carcinoma Mimics

Actinic keratosis Superficial xerosis or seborrheic dermatitis

â–  Actinic keratosis after field therapy with 5-fluorouracil
(left photo)

â–  Often easier to feel than to see
■ Superficial keratotic papules “come and go” on sun-damaged skin

â–  May occur in same distribution on forehead, central face
â–  Scale is less keratotic and will improve with moisturizers,

mild topical steroids

Cutaneous horn/keratotic scale Warts

â–  The protypic keratotic scale of actinic keratoses and SCC is
formed by keratin and can result in a cutaneous horn

â–  Cutaneous horns should generally be biopsied to rule out SCC

â–  Usually skin-colored to pink, texture more verrucous than
keratotic

â–  May be filiform
â–  Often have hemorrhagic punctae that can be seen with a

magnifying glass or dermatoscope

Squamous cell carcinoma Seborrheic keratosis

â–  Keratoacanthomas are SCCs that arise rapidly and have a
crateriform center

â–  Often have a smooth but firm border
â–  SCCs can become quite large if left untreated (Note: highest

sites of metastasis are the scalp, lips, and ears)

â–  Often have a verrucous texture
■ Appear like a “stuck-on” or flattened ball of wax
â–  May crumble or bleed if picked
â–  Specific features on dermoscopy such as milia-like cysts or

comedone-like openings are reassuring, if present
â–  May be erythematous if inflamed

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Table 6-5 Pink Lesions: Basal Cell Carcinoma
and Its Mimics

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. BCC consists of
immature cells similar to those in the basal layer of the epidermis, and account for roughly 80% of all skin cancers. BCCs should
be biopsied for confirmation before treatment. Review the BCC features below and how they contrast with mimics that are benign.

Basal Cell Carcinomas Mimics

Superficial basal cell carcinoma Actinic keratosis and squamous
cell carcinoma in situ

â–  Pink patch that does not heal
â–  May have focal scaling

â–  Actinic keratosis or squamous cell carcinoma in situ usually
has keratotic scaling

Nodular basal cell carcinoma Sebaceous hyperplasia

â–  Pink papule, often with translucent or pearly appearance
and overlying telangiectasias

â–  May have focal pigmentation
â–  Dermoscopy shows arborizing vessels, focal pigment

globules, and other specific patterns

â–  Yellowish globular papules, often with central dell, on
forehead and cheeks

â–  Dermoscopy shows telangiectasias that go around sebaceous
glands rather than over them as in BCC

Table 3.1 Motivational Interviewing: A Clinical Example

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Basal Cell Carcinomas Mimics

Nodular basal cell carcinoma (continued ) Fibrous papule

â–  1 cm pearly pink plaque with central depression and
overlying arborizing telangiectasias on nasal ala

â–  Skin-colored to pink papule on the nose, without
telangiectasias

â–  May become excoriated

Ulcerated basal cell carcinoma Squamous cell carcinoma

■ Non-healing ulcer, resulting in “rolled border” ■ May also be ulcerated
â–  Firmer at edges than BCC

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Table 6-6 Brown Lesions:
Melanoma and Its Mimics

Most patients have brown spots on their body surface if you look thoroughly. 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. The
best way to detect a melanoma is to do numerous skin examinations so that you recognize brown lesions that are benign. With
enough practice, when you see a melanoma, it will stick out as the “ugly duckling.” Review the ABCDE rule and photographs on
pp. 178–180, which provide additional helpful identifiers and comparisons.

Melanomas Mimics

Amelanotic melanoma Skin tags or intradermal nevi

â–  Usually in very fair-skinned people
â–  Evolution or rapid change is the most important feature,

because variegation or dark pigment is missing in this type

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

Melanoma in situ Solar lentigo

â–  On sun-exposed or sun-protected skin
â–  Look for ABCDE features

â–  On sun-exposed skin
â–  Light brown and uniform in color but may be asymmetric

Table 3.1 Motivational Interviewing: A Clinical Example

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The Skin, Hair, and Nails 201

(continued)

Melanomas Mimics

Melanoma Dysplastic nevus

â–  May arise de novo or in existing nevi and exhibits ABCDEs
â–  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

Melanoma Inflamed seborrheic keratosis

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

â–  Can sometimes mimic a melanoma if it has an
erythematous base

â–  Dermoscopy helps the trained eye distinguish these

Melanoma Seborrheic keratosis

â–  May be uniform in color but asymmetric; key feature is
rapid change or Evolution

â–  Stuck-on and verrucous, may be darkly pigmented

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Table 6-6 Brown Lesions:
Melanoma and Its Mimics (Continued )

Melanomas Mimics

Acral melanoma Acral nevus

â–  Rapid change or evolution helps detect acral melanoma
â–  Consider biopsies if >7 mm, rapidly growing, or concerning

features on dermoscopy

â–  Likely benign if <7 mm and has a reassurance pattern on
dermoscopy, such as the parallel furrow or lattice patterns

Melanoma with blue-black areas Blue nevus

â–  Blue-black areas are concerning for melanoma, especially if
they are asymmetric

â–  Blue nevi have a homogenous blue-gray appearance,
clinically and on dermoscopy

Table 3.1 Motivational Interviewing: A Clinical Example

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Finding the Ugly Duckling: As you evaluate changing brown lesions in the context of the patient’s other nevi and lentigines,
the “ugly duckling” is the nevus that looks different from the patient’s other nevi. A patient may make many atypical nevi with
surrounding macular components and central papular components, but they all look the same. Find the patient’s signature nevus,
then search for the ugly duckling that looks different from the patient’s typical “signature” nevi.

Most dermatologists now rely on a dermatoscope to evaluate pigmented lesions, which allows them to detect melanomas when
they are thinner. With training, dermoscopy can help distinguish nevi with reassuring patterns from possible early melanomas.
Even without dermoscopy, however, a keen eye actively inspecting the skin for “ugly ducklings” is likely to detect melanomas
when they arise.

This patient has multiple atypical nevi, but the one on his right back just lateral to midline stands out as the “ugly duckling”
because it has three colors; the white area showed melanoma in situ on biopsy.

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Table 6-7 Acne Vulgaris—Primary and Secondary Lesions

Acne vulgaris is the most common cutaneous disorder in the United States, affecting more than 85% of adolescents.33 Acne is a
disorder of the pilosebaceous unit that involves proliferation of the keratinocytes at the opening of the follicle; increased
production of sebum, stimulated by androgens, which combines with keratinocytes to plug the follicular opening; growth of
Propionibacterium acnes, an anaerobic diphtheroid normally found on the skin; and inflammation from bacterial activity and
release of free fatty acids and enzymes from activated neutrophils. Cosmetics, humidity, heavy sweating, and stress are
contributing factors. Most recommendations for treatment of acne are divided along its morphologic subdivisions: comedonal
(mild), inflammatory (moderate), and nodulocystic (severe).

Lesions appear in areas with the greatest number of sebaceous glands, namely the face, neck, chest, upper back, and upper
arms. They may be primary, secondary, or mixed.

Primary Lesions Secondary Lesions

Mild Acne: Open and closed comedones,
occasional papules

Moderate Acne: Comedones, papules,
pustules

Severe Cystic Acne

Acne with Pitting and Scars

Table 3.1 Motivational Interviewing: A Clinical Example

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Table 6-8 Vascular and Purpuric Lesions
of the Skin

Vascular Lesions

Spider Angioma
a

Spider Vein
a

Cherry Angioma

Color and Size Fiery red; from very small to
2 cm

Bluish; size variable, from
very small to several inches

Bright or ruby red; may become
purplish with age; 1–3 mm

Shape Central body, sometimes
raised, surrounded by
erythema and radiating legs

Variable; may resemble a
spider or be linear, irregular,
cascading

Round, flat, or sometimes
raised; may be surrounded
by a pale halo

Pulsatility and Effect
of Pressure

Often seen in center of the spider
when pressure with a glass slide
is applied; pressure on the body
causes blanching of the spider

Absent; pressure over the
center does not cause
blanching, but diffuse
pressure blanches the veins

Absent; may show partial
blanching, especially if
pressure applied with edge of
a pinpoint

Distribution Face, neck, arms, and upper trunk;
almost never below the waist

Most often on the legs, near
veins; also on the anterior chest

Trunk; also extremities

Significance Single spider angiomas are
normal and are common on the
face and chest; also seen in
pregnancy and liver disease

Often accompanies increased
pressure in the superficial
veins, as in varicose veins

None; increases in size and
numbers with aging

Purpuric Lesions

Petechia/Purpura Ecchymosis

Color and Size Deep red or reddish purple, fading away over
time; petechia, 1–3 mm; purpura are larger

Purple or purplish blue, fading to green,
yellow, and brown with time; ariable size,
larger than petechiae, >3 mm

Shape Rounded, sometimes irregular; flat Rounded, oval, or irregular; may have a central
subcutaneous flat nodule (a hematoma)

Pulsatility and Effect
of Pressure

Absent; no effect from pressure Absent; no effect from pressure

Distribution Variable Variable

Significance Blood outside the vessels; may suggest a
bleeding disorder or, if petechiae, emboli to
skin; palpable purpura in vasculitis

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

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Table 6-9 Signs of Sun Damage

Sun damage is one of the most important clues that a patient is at risk of skin cancer. Study carefully the following indicators of
sun damage accrued throughout life. These indicators should prompt close inspection for pink lesions that are possible basal cell
carcinomas; rough or keratotic lesions that may be actinic keratoses or squamous cell carcinomas; or asymmetric, multicolored, or
changing lesions that could be melanoma. Counsel affected patients about proper sun protection, not only for themselves but for
their families.

Solar lentigo: Bilaterally symmetric brown macules located
on sun-exposed skin, including the face, shoulders, and arms
and hands

Solar elastosis: Yellowish white macules or papules in
sun-exposed skin, especially on the forehead

Actinic purpura: Ecchymoses limited to the dorsal forearms
and hands but not extending above the “shirt sleeve” line on
the upper arm

Poikiloderma: Red patches in sun-damaged areas, espe-
cially the V of the neck, and lateral neck (usually sparing the
shadow inferior to the chin) with fine telangiectasias, and
both hyper- and hypopigmentation

Wrinkles: Increased sun damage and tanning leads to deeper
wrinkles at an earlier age

Cutis rhomboidalis nuchae: Deep wrinkles on the pos-
terior neck that “criss-cross”

Table 3.1 Motivational Interviewing: A Clinical Example

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Table 6-10 Systemic Diseases
and Associated Skin Findings

Systemic Disease Associated Findings or Diagnoses

Addison disease Hyperpigmentation of oral mucosa as well as sun-exposed skin, sites of trauma, and
creases of palms and soles

Acquired immune deficiency
syndrome

Human papillomavirus, herpes simplex virus, varicella zoster virus, cytomegalovirus,
molluscum contagiosum, bacterial abscesses, mycobacterium (tuberculosis, leprae,
avium) infections, candidiasis, deep fungal infections (cryptococcus, histoplasmosis),
oral hairy leukoplakia, Kaposi sarcoma, oral and anal squamous cell carcinoma,
acquired ichthyosis, severe psoriasis, severe seborrheic dermatitis, eosinophilic
folliculitis

Chagas disease (American
trypanosomiasis)

Unilateral conjunctivitis and lid edema associated with preauricular lymphadenopathy

Chronic renal disease Pallor, xerosis, uremic frost, pruritus, “half and half” nails, calciphylaxis.

CREST syndrome Calcinosis, Raynaud phenomenon, sclerodactyly, matted telangiectasias of face and
hands (palms)

Crohn disease Erythema nodosum, pyoderma gangrenosum, enterocutaneous fistulas, aphthous ulcers

Cushing disease Striae, atrophy, purpura, ecchymoses, telangiectasias, acne, moon facies, buffalo hump,
hypertrichosis

Dermatomyositis Violaceous erythema as macules, patches or papules in periocular region (heliotrope),
on interphalangeal joints (Gottron sign), and on upper back and shoulders (shawl
sign); poikiloderma in sun-exposed areas; periungual telangiectasia, ragged cuticles
(Samitz sign)

Diabetes Pruritus, diabetic dermopathy, acanthosis nigricans, candidiasis, neuropathic ulcers,
necrobiosis lipoidica, eruptive xanthomas

Disseminated intravascular
coagulation

Purpura, petechiae, hemorrhagic bullae, induration, necrosis

Dyslipidemias Xanthomas (tendon, eruptive, and tuberous), xanthelasma (may also occur in healthy people)

Gonococcemia Purple to grey macules, papules or hemorrhagic pustules distributed over acral and
periarticular surfaces

Hemochromatosis Skin bronzing and hyperpigmentation

Hypothyroidism Dry, rough, and pale skin; coarse and brittle hair; myxedema; alopecia (lateral third of
the eyebrows to diffuse); skin cool to touch; thin and brittle nails

Hyperthyroidism Warm, moist, soft, and velvety skin; thin and fine hair; alopecia; vitiligo; pretibial
myxedema (in Graves disease); hyperpigmentation (local or generalized)

Infective endocarditis Janeway lesions, Osler nodes, splinter hemorrhages, petechiae

(continued)

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Table 6-10 Systemic Diseases
and Associated Skin Findings (Continued )

Systemic Disease Associated Findings or Diagnoses

Kawasaki disease Mucosal erythema (lips, tongue, and pharynx), strawberry tongue, cherry red lips,
polymorphous rash (primarily on trunk), erythema of palms and soles with later
desquamation of fingertips

Liver disease Jaundice, spider angiomas and other telangiectasias, palmar erythema, Terry nails,
pruritus, purpura, caput medusae

Leukemia/lymphoma Pallor, exfoliative erythroderma, nodules, petechiae, ecchymoses, pruritus, vasculitis,
pyoderma gangrenosum, bullous diseases

Leukocytoclastic vasculitis (post-
capillary venules)

Palpable purpura, purpuric wheals, hemorrhagic bullae in dependent areas

Lymphogranuloma venereum Lymphadenopathy above and below Poupart ligament (groove sign)

Medium vessels vasculitides (e.g.,
polyarteritis nodosa, granulomatosis
with polyangiitis, eosinophilic
granulomatosis with polyangiitis,
microscopic polyangiitis)

Livedo racemosa, purpuric nodules, ulcers

Meningococcemia Angular or stellate purpuric patches and plaques with gunmetal gray center. Progresses
to ecchymoses, bullae, necrosis

Neurofibromatoses 1 (von
Recklinghausen syndrome)

Neurofibromas, café-au-lait spots, freckling in the axillae (Crowe sign), plexiform
neurofibroma

Pancreatitis (hemorrhagic) Bruising and induration over the costovertebral angle (Grey Turner sign), Cullen sign,
panniculitis

Pancreatic carcinoma Panniculitis, migratory thrombophlebitis (Trousseau sign)

Porphyria cutanea tarda Photosensitivity with bullae and skin fragility on dorsal hands and forearms; bullae
rupture and heal with scarring and milia; hypertrichosis of the face; bronzing of skin
when associated with hemochromatosis

Pyoderma gangrenosum Painful pustule quickly progressing to ragged ulcer with sharply marginated violaceous
border and undermined edges

Rocky Mountain spotted fever Pink or reddish papules progressing to purpuric papules; starts on wrists and ankles
and spreads to palms and soles and then to trunk and face

Sarcoidosis Red-brown plaques, often annular, typically involving the head and neck and especially
the nose and ears; may show apple jelly color with dermoscopy

Systemic lupus erythematosus Malar erythema (mid cheeks, spans bridge of nose), relative sparing of nasolabial folds,
periungual erythema, interphalangeal erythema

Table 3.1 Motivational Interviewing: A Clinical Example

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Table 6-11 Hair Loss

When taking a complete history of hair loss, include the duration, acuity of onset, cause from decreased hair density or increased
shedding, the pattern (diffuse or localized), medication history, hair care practices, and associated medical conditions or stressors.
Decrease in hair density is usually caused by male or female pattern hair loss, but less commonly by scarring alopecias. Hair shedding from
the roots is often caused by telogen effluvium, alopecia areata, anagen effluvium (insults to the hair shaft from exposure to agents like
chemotherapy) or less commonly, scarring alopecias. Perform a hair pull test to look for the percentage of telogen hairs. Hair shedding
from breakage at the hair shaft is often caused by tinea capitis, improper hair care, and less commonly hair shaft disorders or anagen
effluvium. Perform a tug test to look for hair fragility. See Figures 6-27 and 6-28 on p. 188 for examples of the hair pull test and tug test.

Generalized or Diffuse Hair Loss

Male and female pattern hair loss affects over half of men by their 50 years of age, and over half of women by their 80 years of
age. 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. Severity is described by standardized classifications: Norwood-Hamilton (men)
and Ludwig (women). The hair pull test is normal or only pulls a few hairs.

Male pattern hair loss (MPHL) Female pattern hair loss (FPHL)

Telogen Effluvium and Anagen Effluvium

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

Focal Hair Loss

Alopecia Areata

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.

(continued)

210 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G210 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

Table 6-11 Hair Loss (Continued )

Tinea Capitis (“Ringworm”)

There are round scaling patches of alopecia, mostly seen in children. There may be “black dots” of broken hairs and comma or
corkscrew hairs on dermoscopy. Usually caused by Trichophyton tonsurans from humans, and less commonly, Microsporum canis
from dogs or cats. Boggy plaques are called kerions.

Scarring Alopecia

Scarring on the scalp is characterized by shiny skin, complete loss of hair follicles, and often, discoloration. Presence of any
scarring should prompt referral to a dermatologist for possible scalp biopsy if the patient desires treatment. Examples of scarring
alopecia include central centrifugal scarring alopecia and discoid lupus erythematosus, among others.

Central centrifugal scarring alopecia Discoid lupus scarring alopecia

Hair Shaft Disorders

Patients with abnormal hair from birth, as in this patient with a genetic condition called monilethrix, should be referred to
dermatology.

Hair shaft disorder with alternating bands

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. *See also Hair Loss Help. Hair loss classifications. Available at http://www.hairlosshelp.com/hair_loss_research/hair_loss_charts.
cfm. Accessed February 13, 2015.

Sources of photo: Alopecia Areata [left]—Hall JC. Sauer’s Manual of Skin Diseases, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.

Table 3.1 Motivational Interviewing: A Clinical Example

C H A P T E R 6 |

The Skin, Hair, and Nails 211

Table 6-12 Findings in or Near the Nails

Paronychia
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 species, and may spread until it
completely surrounds the nail plate. Creates a felon if it extends into the pulp space of the
finger. Arises from local trauma due to nail biting, manicuring, or frequent hand immersion
in water. Chronic infections may be related to Candida.

Clubbing of the Fingers
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° or more,
and the nail bed feels spongy or floating. The mechanism is still unknown but involves
vasodilatation with increased blood flow to the distal portion of the digits and changes in
connective tissue, possibly from hypoxia, changes in innervation, genetics, or a platelet-
derived growth factor from fragments of platelet clumps. Seen in congenital heart disease,
interstitial lung disease and lung cancer, inflammatory bowel diseases, and malignancies.

Habit Tic Deformity
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. Pressure on the nail matrix causes the nail to grow out
abnormally. Avoidance of the behavior leads to normal nail growth.

Melanonychia
Melanonychia is 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 thin
uniform streak may be caused by a nevus, but a wide streak, especially if growing or
irregular, could represent a subungual melanoma.

Onycholysis
A painless separation of the whitened opaque nail plate from the pinker translucent nail
bed. Fingernails that extend past the fingertip are more likely to result in the traumatic
shearing forces that produce onycholysis. Starts distally and progresses proximally,
enlarging the free edge of the nail. Local causes include trauma from excess manicuring,
psoriasis, fungal infection, and allergic reactions to nail cosmetics. Systemic causes include
diabetes, anemia, photosensitive drug reactions, hyperthyroidism, peripheral ischemia,
bronchiectasis, and syphilis.

(continued)

212 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G212 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

Onychomycosis
The most common cause of nail thickening and subungual debris is onychomycosis, most
often from the dermatophyte Trichophyton rubrum, but also from other dermatophytes and
some molds such as Alternaria and Fusarium species. Onychomycosis affects 1 in 5 over
age 60. The best prevention is to treat and prevent tinea pedis. Only half of all nail
dystrophies are caused by onychomycosis, so a positive fungal culture, potassium
hydroxide exam, or pathologic evaluation of nail clippings is recommended before treating
with oral antifungals.

Terry Nails
Nail plate turns white with a ground-glass appearance, a distal band of reddish brown, and
obliteration of the lunula. Commonly affects all fingers, although may appear in only one
finger. Seen in liver disease, usually cirrhosis, heart failure, and diabetes. May arise from
decreased vascularity and increased connective tissue in nail bed.

Transverse Linear Depressions (Beau Lines)
Transverse depressions of the nail plates, usually bilateral, resulting from temporary
disruption of proximal nail growth from systemic illness. Timing of the illness may
be estimated by measuring the distance from the line to the nail bed (nails grow
approximately 1 mm every 6 to 10 days). Seen in severe illness, trauma, and cold
exposure if Raynaud disease is present.

Pitting
Punctate depressions of the nail plate caused by defective layering of the superficial nail
plate by the proximal nail matrix. Usually associated with psoriasis but also seen in Reiter
syndrome, sarcoidosis, alopecia areata, and localized atopic or chemical dermatitis.

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

Table 6-12 Findings in or Near the Nails (Continued )

C H A P T E R 6 |

The Skin, Hair, and Nails 213

Table 6-13 Pressure Ulcers

Pressure (decubitus) ulcers usually develop over bony prominences subject to unrelieved pressure, resulting in ischemic damage to
underlying tissue. Prevention is important: inspect the skin thoroughly for early warning signs of erythema that still blanches with
pressure, especially in patients with risk factors. Pressure ulcers form most commonly over the sacrum, ischial tuberosities, greater
trochanters, and heels. A commonly applied staging system, based on depth of destroyed tissue, is illustrated below. Note that
necrosis or eschar must be debrided before ulcers can be staged. Ulcers may not progress sequentially through the four stages.

Inspect ulcers for signs of infection (drainage, odor, cellulitis, or necrosis). Fever, chills, and pain suggest underlying osteomyelitis.
Address the patient’s overall health, including comorbid conditions such as vascular disease, diabetes, immune deficiencies, collagen
vascular disease, malignancy, psychosis, or depression; nutritional status; pain and level of analgesia; risk for recurrence;
psychosocial factors such as learning ability, social supports, and lifestyle; and evidence of polypharmacy, overmedication, or
abuse of alcohol, tobacco, or illicit drugs.34,35

Risk Factors for Pressure Ulcers

â–  Decreased mobility, especially if accompanied by increased
pressure or movement causing friction or shear stress

â–  Decreased sensation, from brain or spinal cord lesions or
peripheral nerve disease

Stage I

Presence of a reddened area that fails to blanch with pressure,
and changes in temperature (warmth or coolness),
consistency (firm or boggy), sensation (pain or itching), or
color (red, blue, or purple on darker skin; red on lighter skin)

â–  Decreased blood flow from hypotension or microvascular
disease such as diabetes or atherosclerosis

â–  Fecal or urinary incontinence
â–  Presence of fracture
â–  Poor nutritional status or low albumin

Stage II

The skin forms a blister or sore. Partial-thickness skin loss or
ulceration involving the epidermis, dermis, or both

Stage III

A crater appears in the skin, with full-thickness skin loss
and damage to or necrosis of subcutaneous tissue that may
extend to, but not through, underlying muscle

Stage IV

The pressure ulcer deepens. There is full-thickness skin loss,
with destruction, tissue necrosis, or damage to underlying
muscle, bone, and sometimes tendons and joints

Source: Used with permission of National Pressure Ulcer Advisory Panel, Washington, DC.

214 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

REFERENCES

References
1. Eichenfeld LF, Tom WL, Berger TG, et al. Guidelines of care for the

management of atopic dermatitis. J Am Acad Dermatol. 2014;71:116.
2. National Eczema Association. Available at http://nationaleczema.

org/eczema-products/moisturizers/. Accessed October 27, 2014.
3. Stern RS. Prevalence of a history of skin cancer in 2007: results of

an incidence-based model. Arch Dermatol. 2010;146:279.
4. Siegel R, Desantis C, Jemal A. Cancer statistics, 2015. CA Cancer J

Clin. 2015;65:5.
5. Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics

Review, 1975–2011. Bethesda, MD: National Cancer Institute; 2014.
6. American Cancer Society. Key statistics about Melanoma Skin Can-

cer. Available at http://www.cancer.org/cancer/skincancer-mela-
noma/detailedguide/melanoma-skin-cancer-key-statistics.
Accessed February 2, 2015.

7. Naeyaert JM, Brochez L. Clinical practice. Dysplastic nevi. N Engl
J Med. 2003;349:2233.

8. American Academy of Dermatology. Skin cancer. Available at https://
www.aad.org/dermatology-a-to-z/diseases-and-treatments/q—t/
skin-cancer. Accessed February 11, 2015.

9. National Cancer Institute. Genetics of Skin Cancer (PDQ®). Mela-
noma. Available at http://www.cancer.gov/cancertopics/pdq/genetics/
skin/HealthProfessional/page4. Accessed February 14, 2015.

10. El Ghissassi F, Baan R, Straif K, et al. A review of human carcino-
gens—part D: radiation. Lancet Oncol. 2009;10:751.

11. Glanz K, Schoenfeld ER, Steffen A. A randomized trial of tailored
skin cancer prevention messages for adults: Project SCAPE. Am J
Public Health. 2010;100:735.

12. Lin JS, Eder M, Weinmann S. Behavioral counseling to prevent skin
cancer: a systematic review for the U.S. Preventive Services Task
Force. Ann Intern Med. 2011;154:190. See also http://www.ncbi.
nlm.nih.gov/books/NBK53508/. Accessed February 15, 2015.

13. Moyer VA. Behavioral counseling to prevent skin cancer: U.S. Pre-
ventive Services Task Force recommendation statement. Ann Intern
Med. 2012;157:59. See also http://www.uspreventiveservicestask-
force.org/Page/Topic/recommendation-summary/skin-cancer-
counseling?ds=1&s=. Accessed February 15, 2015.

14. Green AC, Williams GM, Logan V, et al. Reduced melanoma after
regular sunscreen use: randomized trial follow-up. J Clin Oncol,
2011;29:257.

15. American Academy of Dermatology. How do I prevent skin cancer.
Available at https://www.aad.org/spot-skin-cancer/understanding-
skin-cancer/how-do-i-prevent-skin-cancer. Accessed February 11,
2015.

16. Skin Cancer Foundation. Sun protection. Available at http://www.skin-
cancer.org/prevention/sun-protection. Accessed February 15, 2015.

17. U.S. Preventive Services Task Force. Screening for skin cancer.
Recommendation statement. Ann Intern Med. 2009;150:188. See
also http://www.uspreventiveservicestaskforce.org/Page/Topic/
recommendation-summary/skin-cancer-screening?ds=1&s=.
Accessed February 15, 2015.

18. Wolff T, Tai E, Miller T. Screening for skin cancer: an update of the
evidence for the U.S. Preventive Services Task Force. Ann Intern

Med. 2009;150:194. See also http://www.ncbi.nlm.nih.gov/books/
NBK34051/. Accessed February 15, 2015.

19. Siegel R, Desantis C, Jemal A. Colorectal cancer statistics, 2014. CA
Cancer J Clin. 2014;64:104.

20. Aitken JF, Elwood M, Baade PD, et al. Clinical whole-body skin
examination reduces the incidence of thick melanomas. Int J Can-
cer. 2010;126:450.

21. Katalinic A, Waldmann A, Weinstock MA, et al. Does skin cancer
screening save lives? An observational study comparing trends in
melanoma mortality in regions with and without screening. Can-
cer. 2012;118:5395.

22. Swetter SM, Pollitt RA, Johnson TM, et al. Behavioral determinants
of successful early melanoma detection. Cancer. 2012;118:3725.

23. Grange F, Barbe L, Mas F, et al. The role of general practitioners in
diagnosis of cutaneous melanoma: a population-based study in
France. Br J Dermatol. 2012;167:1351.

24. Mayer JE, Swetter SM, Fu T, et al. Screening, early detection, edu-
cation, and trends for melanoma: current status (2007–2013) and
future directions, Parts I and II. J Am Acad Dermatol. 2014;71:
599; 611.

25. Eide MJ, Asgari NM, Fletcher SW, et al. Effects on skills and prac-
tice from a web-based skin cancer course for primary care provid-
ers. J Am Board Fam Med. 2013;26:648.

26. Skinsight INFORMED Skin Cancer Education Series. Melanoma
and Skin Cancer Early Detection. http://www.skinsight.com/info/
for_professionals/skin-cancer-detection-informed/skin-cancer-
education. Accessed February 15, 2015.

27. Abbasi NR, Shaw HM, Rigel DS, et al. Early diagnosis of cutaneous
melanoma revisiting the ABCD criteria. JAMA. 2004;292:2771.

28. American Cancer Society. Skin exams. Available at http://www.
cancer.org/cancer/skincancer-melanoma/moreinformation/
skincancerpreventionandearlydetection/skin-cancer-prevention-
and-early-detection-skin-exams. Accessed February 11, 2015.

29. McPherson M, Elwood M, English DR, et al. Presentation and
detection of invasive melanoma in a high-risk population. J Am
Acad Dermatol. 2006;54:783.

30. Zalaudek I, Kittler H, Marghoob AA, et al. Time required for a
complete skin examination with and without dermoscopy: a pro-
spective, randomized multicenter study. Arch Dermatol. 2008;
144:509.

31. Learn Derm. http://www.visualdx.com/learnderm/. Accessed
February 15, 2015.

32. Mubki T, Rucnicka L, Olszewska M, et al. Evaluate and diagnosis
of the hair loss patient. J Am Acad Dermatol. 2014;71:415.

33. Thiboutot D, Gollnick H, Bettoli V, et al. New insights into the
management of acne: an update from the Global Alliance
to Improve Outcomes in Acne group. J Am Acad Dermatol. 2009;
60(5 Suppl):S1.

34. Smith TE, Totten A, Hickam DH, et al. Pressure ulcer treatment
strategies: a systemic comparative effectiveness review. Ann Intern
Med. 2013;159:39.

35. VanGilder C, MacFarlane G, Meyer S, et al. Body mass index,
weight, and pressure ulcer prevalence: an analysis of the 2006–
2007 International Pressure Ulcer Prevalence Surveys. J Nurs Care
Qual. 2009;24:127.

C H A P T E R 7 |

The Head and Neck 215

Many critical structures like the sensory organs, cranial nerves (CNs), and major
blood vessels originate in the head and neck. To help students integrate this
complex anatomy and physiology with the skills of physical examination, this
chapter follows a special format. The Health History and the Health Promotion
and Counseling sections cover the “HEENT” components—Head, Eyes, Ear,
Nose, and Throat—as a unit since head and neck symptoms, as well as preven-
tion strategies, are often interconnected. However, Anatomy and Physiology and
Techniques of Examination are grouped together in five combined sections due
to the close linkage between anatomic structures and function and techniques of
examination, especially for the examination of the eyes (Fig. 7-1).

C H A P T E R

7
The Head and Neck

The Bates’ suite offers these additional resources to enhance learning and facilitate
understanding of this chapter:
■ Bates’ Pocket Guide to Physical Examination and History Taking, 8th edition
■ Bates’ Visual Guide to Physical Examination (Vol. 7: Head, Eyes, and Ears; Vol. 8: Nose, Mouth,

and Neck)
â–  thePoint online resources, for students and instructors: http://thepoint.lww.com

F I G U R E 7 – 1 . Test the complex

anatomy and physiology of vision.

Common or Concerning Symptoms

● Headache
● Change in vision: blurred vision, loss of vision, floaters, flashing lights
● Eye pain, redness, or tearing
● Double vision (diplopia)
● Hearing loss, earache, ringing in the ears (tinnitus)
● Dizziness and vertigo
● Nosebleed (epistaxis)
● Sore throat, hoarseness
● Swollen glands
● Goiter

Many symptoms of the head and neck represent common benign processes, but
sometimes these symptoms reflect a serious underlying condition. Careful
attention to the interview and physical examination, with a focus on features and

The Health History

216 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE HEALTH HISTORY

findings that do not fit a typical benign pattern, can often distinguish a common
condition of the head and neck from a serious underlying disease.

The Head

Headache is one of the most common symptoms in clinical practice, with a life-
time prevalence of 30% in the general population.1,2 Among types of headaches,
tension headache predominates, affecting half of all individuals during their
lifetime.3 Headaches are generally classified as primary (without an identified
underlying disease) or secondary (with an identified underlying disease). How-
ever, every headache warrants careful evaluation for life-threatening secondary
causes such as meningitis, subarachnoid hemorrhage, or mass lesion. Elicit a
full description of every headache and its seven attributes (see p. 79). Is it uni-
lateral or bilateral? Severe with sudden onset, like a thunderclap? Steady or
throbbing? Continuous or intermittent? Is there an aura? Is the headache “typi-
cal” or is there something different?

Look for important signs (“red flags”) that warn of headaches needing prompt
investigation.

See Tables 7-1 and 7-2 on Primary

Headaches and Secondary Headaches

and Cranial Neuralgias on pp. 267–269.

Primary headaches include migraine,
tension, cluster, and chronic daily

headaches; secondary headaches arise
from underlying structural, systemic,

or infectious causes such as meningi-

tis or subarachnoid hemorrhage and

may be life-threatening.4–6

The International Classification of
Headache Disorders, now in its second
iteration, continues to evolve.5,7–9

Thunderclap headaches reaching

maximal intensity over several min-

utes occur in 70% of patients with

subarachnoid hemorrhage, and are
often preceded by a sentinel leak
headache from a vascular leak into
the subarachnoid space.10

Headache Warning Signs

● Progressively frequent or severe over a 3-month period
● Sudden onset like a “thunderclap” or “the worst headache of my life”
● New onset after age 50 years
● Aggravated or relieved by change in position
● Precipitated by Valsalva maneuver or exertion
● Associated symptoms of fever, night sweats, or weight loss
● Presence of cancer, HIV infection, or pregnancy
● Recent head trauma
● Change in pattern from past headaches
● Lack of a similar headache in the past
● Associated papilledema, neck stiffness, or focal neurologic deficits

The three most important attributes of headache are its severity, its chronologic
pattern, and its associated symptoms. Is the headache severe and of sudden onset?
Does it intensify over several hours? Is it episodic? Or is it chronic or recurring?
Is there a recent change in its pattern? Does the headache recur at the same time
every day? What other symptoms, especially weakness or numbness in an arm
or leg?

After your usual open-ended assessment, ask the patient to point to the area of
pain or discomfort.

If headache is severe and of sudden

onset, consider subarachnoid hemor-
rhage or meningitis.10

Migraine and tension headaches are
episodic and tend to peak over several

hours. New and persisting, progres-

sively severe headaches raise concerns

of tumor, abscess, or mass lesion.

Unilateral headache occurs in

migraine and cluster headaches.4,11
Tension headaches often arise in the

temporal areas; cluster headaches

may be retro-orbital.

E X A M P L E S O F A B N O R M A L I T I E S

C H A P T E R 7 |

The Head and Neck 217

THE HEALTH HISTORY

Ask about associated symptoms such as nausea and vomiting.

Is there a prodrome of unusual feelings such as euphoria, craving for food,
fatigue, or dizziness? Does the patient report an aura with neurologic symptoms,
such as change in vision, numbness, or weakness?

Note that, due to increased risk of ischemic stroke and cardiovascular disease, the
World Health Association advises women with migraines over age 35 years and
women with migraines with aura avoid use of estrogen–progestin contracep-
tives.12–15

Ask if coughing, sneezing, or changing the position of the head affects the head-
ache. If head position affects the headache, ask if leaning forward or lying down
increases the headache, or if lying down increases the headache.

Is there any overuse of analgesics, ergotamines, or triptans?

Ask about family history.

The Eyes

Begin with open-ended questions such as “How is your vision?” and “Have you
had any trouble with your eyes?” If the patient reports a change in vision, pursue
the related details.

â–  Is vision worse during close work or at distances?

â–  Is there blurred vision? If yes, is the onset sudden or gradual? If sudden and
unilateral, is the visual loss painless or painful?

Nausea and vomiting are common with

migraine, but also occur with brain
tumors and subarachnoid hemorrhage.

Approximately 60% to 70% of

patients with migraine have a symp-
tom prodrome prior to onset. About a

third experience a visual aura, such as

spark photopsias (flashes of light),

fortifications (zig-zag arcs of light),

and scotomas (areas of visual loss

with surrounding normal vision).

Valsalva maneuvers and leaning for-

ward may increase pain from acute
sinusitis. Valsalva and lying down may
increase pain from mass lesions due

to changing intracranial pressure.

Medication for overuse headache may
cause headache if present ≥15 days a
month for three months and reverts

to <15 days a month when the medi-
cation is discontinued.16

Genetic inheritance is present in 30%

to 50% of patients with migraine.11,17

Difficulty with close work suggests

hyperopia (farsightedness) or presby-
opia (aging vision), or, if with distances,
myopia (nearsightedness).

If sudden visual loss is unilateral and
painless, consider vitreous hemor-
rhage from diabetes or trauma, macu-
lar degeneration, retinal detachment,
retinal vein occlusion, or central retinal
artery occlusion.

If painful, causes are usually in the
cornea and anterior chamber such

as corneal ulcer, uveitis, traumatic
hyphema, and acute angle closure
glaucoma.18–20 Optic neuritis from mul-
tiple sclerosis may also be painful.21

Immediate referral is warranted.22,23

E X A M P L E S O F A B N O R M A L I T I E S

218 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

THE HEALTH HISTORY

â–  Is the visual loss bilateral (sudden bilateral visual loss is rare)? If so, is it
painful?

â–  Is the onset of bilateral visual loss gradual?

â–  Location of visual loss may also be helpful. Is there blurring of the entire field
of vision or only parts of it?

â–  If the visual field defect is partial, is it central, peripheral, or on only one
side?

â–  Are there specks in the vision or areas where the patient cannot see (scoto-
mas)? If so, do they move around in the visual field with shifts in gaze or are
they fixed?

â–  Are there lights flashing across the field of vision? Vitreous floaters may ac-
company this symptom.

â–  Does the patient wear glasses?

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

Check for double vision, or diplopia. If present, find out if the images are side by
side (horizontal diplopia) or on top of each other (vertical diplopia). Does dip-
lopia persist with one eye closed? Which eye is affected?

One kind of horizontal diplopia is physiologic. Hold one finger upright approx-
imately 6 inches in front of your face, a second at arm’s length. When you focus
on either finger, the image of the other is double. A patient who notices this
phenomenon can be reassured.

If bilateral and painless, consider
vascular etiologies such as giant-cell
arteritis or nonphysiologic causes. If
bilateral and painful, consider chemi-
cal or radiation exposures.

Gradual vision loss usually arises from

cataracts or macular degeneration.

Slow central loss occurs in nuclear cata-
ract (p. 276) and macular degeneration24
(p. 242), peripheral loss in advanced

open-angle glaucoma (p. 270), and
one-sided loss with hemianopsia and
quadrantic defects (p. 273).

Moving specks or strands suggest vit-

reous floaters; fixed defects, or scoto-
mas, suggest lesions in the retina or
visual pathways.

Flashing lights with new vitreous

floaters suggest detachment of the

vitreous body from the retina. Prompt

consultation is indicated.25

A red painless eye is seen in subcon-
junctival hemorrhage, a red eye with a
gritty sensation in viral conjunctivitis.
A red painful eye is seen in hyphema,
episcleritis, acute angle closure glau-
coma, herpes keratitis, foreign body,
fungal keratitis, and sarcoid uveitis.26,27
See Table 7-3, Red Eyes, p. 270.

Diplopia is seen in lesions in the
brainstem or cerebellum, and with

weakness or paralysis of one or more

extraocular muscles, as in horizontal
diplopia from palsy of CN III or VI, or
vertical diplopia from palsy of CN III
or IV. Diplopia in one eye, with the

other closed, suggests a problem in

the cornea or lens.

E X A M P L E S O F A B N O R M A L I T I E S

C H A P T E R 7 |

The Head and Neck 219

THE HEALTH HISTORY

The Ears

Opening questions are “How is your hearing?” and “Have you had any trouble
with your ears?” If the patient has noticed a hearing loss, does it involve one or
both ears? Did it start suddenly or gradually? What are the associated symptoms,
if any?

Distinguish conductive loss, which results from problems in the external or mid-
dle ear, from sensorineural loss, resulting from problems in the inner ear, the
cochlear nerve, or its central connections in the brain. Two questions may be
helpful: Does the patient have special difficulty understanding people as they
talk? What happens in a noisy environment?

Pursue symptoms associated with hearing loss, such as earache or vertigo to help
sort out likely causes. Ask about medications that might affect hearing and about
sustained exposure to loud noise.

Complaints of earache, or pain in the ear, are especially common. Ask about asso-
ciated fever, sore throat, cough, and concurrent upper respiratory infection; if
present, these heighten the likelihood of ear infection.

Ask about discharge from the ear, especially if associated with earache or trauma.
Wax or debris in the ear is usually normal.

Tinnitus is a perceived sound that has no external stimulus—commonly, a musical ring-
ing or a rushing or roaring noise in one or both ears. Tinnitus may accompany hearing
loss and often remains unexplained. Occasionally, popping sounds originate in the
temporomandibular joint, or sounds from the vessels in the neck may be audible.

Vertigo is the sensation of true rotational movement of the patient or the sur-
roundings.32 These sensations point primarily to a problem in the labyrinths of
the inner ear, peripheral lesions of CN VIII, or lesions in its central pathways or
nuclei in the brain.

Complaints of dizziness and light-headedness are challenging because they are
often nonspecific and suggest a diverse set of conditions ranging from vertigo to
presyncope, weakness, unsteadiness, and disequilibrium. Clarify by asking what
the patient means by dizziness. Then ask, “Do you feel as if the room is spinning
or tilting (vertigo)? Do your symptoms get worse when you move your head?”
Then, “Do you feel as if you are going to fall or pass out (presyncope)? . . . Or do
you feel you are unsteady or losing your balance (disequilibrium)?”

Hearing loss may also be congenital,

from single gene mutations.28,29

People with sensorineural loss have
trouble understanding speech, often

complaining that others mumble;

noisy environments make hearing

worse. In conductive loss, noisy envi-
ronments may help.

Medications that affect hearing

include aminoglycosides, aspirin,

NSAIDs, quinine, and furosemide.

Pain occurs in the external canal in

otitis externa (inflammation of the
external ear canal) and, deeper within

the ear in otitis media (infection of the
middle ear).30 Pain in the ear may also

be referred from other structures in

the mouth, throat, or neck.

Acute otitis externa and acute or chronic
otitis media with perforation usually
present with yellow-green discharge.

Tinnitus is a common symptom,
increasing in frequency with age.

When associated with hearing loss

and vertigo, suspect Ménière disease.31

See Table 7-4, Dizziness and Vertigo,

p. 271.

See Table 7-4, Dizziness and Vertigo,

p. 271, for distinguishing symptoms

and time course.

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THE HEALTH HISTORY

If there is true vertigo, distinguish peripheral from central neurologic causes (see
Chapter 17, see p. 722). Establish the time course of symptoms. Check for nau-
sea, vomiting, double vision, and gait disturbance. Review the patient’s medica-
tions. Proceed with a careful neurologic examination focusing on presence of
nystagmus and focal neurologic signs.

The Nose and Sinuses

Rhinorrhea refers to drainage from the nose and is often associated with nasal
congestion, a sense of stuffiness or obstruction. These symptoms are frequently
accompanied by sneezing, watery eyes, and throat discomfort, and itching in the
eyes, nose, and throat.33

Do symptoms occur when colds are prevalent and last less than seven days? Do
they occur during the same season each year when pollens are in the air? Are
symptoms triggered by specific animal or environmental exposures? Are there
indoor environmental triggers such as dust or animals?

What remedies has the patient used? For how long? And how well do they work?

Is nasal or sinus congestion preceded by a viral upper respiratory tract infection
(URI)? Is there purulent nasal discharge, loss of smell, tooth pain, or facial pain
made worse by bending forward, ear pressure, cough, or fever?

Ask about drugs that may induce nasal stuffiness.

Inquire about all medications or drugs, particularly oral contraceptives, reser-
pine, alcohol, and cocaine.

Is the nasal congestion only on one side?

Epistaxis is bleeding from the nasal passages. Bleeding can also originate in the
paranasal sinuses or nasopharynx. Note that bleeding from posterior nasal struc-
tures may pass into the throat instead of out through the nostrils. Ask the patient
to pinpoint the source of the bleeding. Is it from the nose, or has the patient
actually coughed up blood (hemoptysis) or vomited blood (hematemesis)? These
conditions have very different causes.

Vertigo represents vestibular disease,
usually from peripheral causes in the

inner ear such as benign positional
vertigo, labyrinthitis, vestibular neuri-
tis, and Ménière disease. Ataxia, diplo-
pia, and dysarthria signal central

neurologic causes in the cerebellum

or brainstem such as cerebral vascular

disease or posterior fossa tumor; also

consider migraine.32 Feeling light-
headed, weak in the legs, or about to

faint points to presyncope from arrhyth-
mia, orthostatic hypotension, or vaso-

vagal stimulation.

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

Seasonal onset or environmental

triggers suggest allergic rhinitis.

Drug-induced rhinitis occurs in exces-
sive use of topical decongestants, or

use of cocaine.

Acute bacterial sinusitis, now termed
rhinosinusitis, is unlikely until viral URI
symptoms persist more than 7 days;

both purulent drainage and facial pain

should be present for diagnosis (sensi-

tivity and specificity are above 50%).34–36

Consider a deviated nasal septum,

nasal polyp, foreign body, Wegener
granuloma, or carcinoma.

Local causes of epistaxis include

trauma (especially nose-picking),

inflammation, drying and crusting of

the nasal mucosa, tumors, and foreign

bodies.

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Is epistaxis a recurrent problem? Has there been easy bruising or bleeding else-
where in the body?

The Mouth, Throat, and Neck

Sore throat or pharyngitis is a frequent complaint, usually associated with an acute
URI. However, sometimes a sore throat is the only symptom.

Centor’s clinical prediction rules for streptococcal and Fusobacterium necropho-
rum pharyngitis have been used in the past to help guide diagnosis and treat-
ment of bacterial infection: fever history, tonsillar exudates, swollen tender
anterior cervical adenopathy, and absence of cough. However, the sensitivity
and specificity of these rules are less than 90%, calling their validity into ques-
tion due to a high rate of unnecessary antibiotic use. Guidelines now recom-
mend rapid antigen testing or throat culture for diagnosis and treatment.37–39

A sore tongue may result from local lesions as well as from systemic illness.

Bleeding from the gums, especially when brushing teeth, is a common symptom.
Ask about local lesions and any tendency to bleed or bruise elsewhere.

Hoarseness refers to a change in voice quality, often described as husky, rough,
harsh, or lower pitched than usual. Causes range from diseases of the larynx to
extralaryngeal lesions that press on the laryngeal nerves.40 Ask the patient about
environmental allergies, acid reflux, smoking, alcohol use, and inhalation of
fumes or other irritants. Also ask if the patient talks a great deal at work.

Is the problem chronic, lasting more than 2 weeks? Is there prolonged tobacco
or alcohol use, cough or hemoptysis, weight loss, or unilateral throat pain?

Ask “Have you noticed any swollen glands or lumps in your neck?” because
patients are often more familiar with lay terms than with “lymph nodes.”

Assess thyroid function and ask about any enlargement of the thyroid gland,
or goiter. To evaluate thyroid function, ask about temperature intolerance and
sweating. Opening questions include, “Do you prefer hot or cold weather?” “Do
you dress more warmly or less warmly than other people?” “What about blan-
kets … do you use more or fewer than others at home?” “Have you noticed any
changes in the texture of your skin?” “Do you perspire more or less than oth-
ers?” “Any new palpitations or change in weight?” Recall that as people grow
older, they sweat less, have less tolerance for cold, and tend to prefer warmer
environments.

Anticoagulants, NSAIDs, vascular mal-

formations, and coagulopathies can

contribute to epistaxis.

Abnormalities include aphthous ulcers
(p. 298) and the sore smooth tongue

of nutritional deficiency (p. 297).

Bleeding gums are usually caused by

gingivitis (p. 295).

If hoarseness is acute, consider voice

overuse, acute viral laryngitis, and
possible neck trauma.

If hoarseness lasts over 2 weeks, refer for

laryngoscopy and consider causes such

as hypothyroidism, reflux, vocal cord nod-
ules, head and neck cancers including

thyroid masses, and neurologic disorders

like Parkinson disease, amyotrophic lateral
sclerosis, or myasthenia gravis.

Enlarged tender lymph nodes com-

monly accompany pharyngitis.

With goiter, thyroid function may be
increased, decreased, or normal; see

Table 7-27, p. 299.

Intolerance to cold, weight gain, dry

skin, and slowed heart rate point to

hypothyroidism; intolerance to heat,
weight loss, moist velvety skin, and

palpitations point to hyperthyroid-
ism. See Table 7-27, p. 299.

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HEALTH PROMOTION AND COUNSELING

Vision and hearing, critical senses for experiencing the world around us, are two
areas of special importance for health promotion and counseling. Oral health,
often overlooked, also merits clinical attention.

Loss of Vision. An estimated 14 million Americans aged 12 years or older
are considered visually impaired, defined as having a visual acuity of ≥20/50 in the
better-seeing eye.41 Vision disorders in healthy young adults are usually refractive
errors. Older adults have more serious disorders, including cataracts, glaucoma,
and age-related macular degeneration. The prevalence of visual impairment
increases dramatically with age, rising from 5% in adults aged 40 to 49 to 26% of
adults 80 years and older.42 In older adults, visual impairment is associated with
decreased functional capacity, poor quality of life, increased risk of fall and injuries,
and loss of independent living. However, vision in ∼80% of visually impaired
Americans can be corrected.41 Because onset can be gradual, those affected may
not recognize their visual decline. Although acknowledging that numerous
treatments can improve visual acuity, in 2009, the U.S. Preventive Services Task
Force (USPSTF) found insufficient evidence to recommend screening by primary
care physicians, assigning screening only a grade I recommendation.43 In contrast,
the American Academy of Ophthalmology strongly recommends a comprehensive
medical eye examination for all adults every 1 to 2 years, depending on age and
risk factors, including formal screening for visual acuity and glaucoma.44 Assessing
vision is a standard component of thorough physical examination. Ask patients
about any problems with face recognition, reading, or performing regular tasks,
and test acuity with the Snellen chart or a hand-held card. Refer patients with an
impairment of ≥20/50 or a one-line difference between the eyes. Examine the lens and
fundi to detect additional disorders.

Primary open-angle glaucoma (POAG) is a leading cause of visual impairment and
blindness in the United States, affecting over 2.5 million adults, including roughly
2% of adults older than age 40 years.45,46 Over half are unaware of having the
disease. In POAG, there is gradual loss of vision in the peripheral visual fields,
resulting from loss of retinal ganglion cell axons. Retinal examination reveals pal-
lor and increasing size of the optic cup, which can enlarge to more than half the
diameter of the optic disc. Risk factors include age ≥65 years, African American

See Chapter 20, Older Adult,

pp. 955–1008.

See pp. 232–233 for testing acuity,

using the Snellen eye chart, and exami-

nation techniques.

Look for clouding of the lens (cataracts),
mottling of the macula, variations in

retinal pigmentation, subretinal hemor-

rhage or exudates (macular degenera-
tion), and change in color and size of
the optic disc (glaucoma). See tech-
niques for testing acuity and using

the Snellen eye chart on p. 232.

E X A M P L E S O F A B N O R M A L I T I E S

Important Topics for Health Promotion
and Counseling

● Loss of vision: cataracts, macular degeneration, glaucoma
● Hearing loss
● Oral health

Health Promotion and
Counseling: Evidence and
Recommendations

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ethnicity, diabetes, myopia, and ocular hypertension (intraocular pressure [IOP]
is ≥21 mm Hg). Not all people with POAG have elevated IOP, and those with
elevated IOP may not develop visual impairment. Further, diagnosis of optic disc
enlargement is variable, even among experts. Nonetheless, glaucoma can be suc-
cessfully treated with medical and surgical interventions, despite possible adverse
events like eye irritation and cataracts. In 2013, the USPSTF found insufficient
evidence for general glaucoma screening by primary care physicians due to the
complexities of diagnosis and treatment, giving only a grade I recommendation.46
However, the American Academy of Ophthalmology strongly recommends peri-
odic glaucoma testing, especially for older and at-risk patients.47

Ultraviolet (UV) light can damage the eyes and cause skin cancers on the eyelids,
including basal cell carcinoma, squamous cell carcinoma, and melanoma. In
addition, there is some evidence that UV light is associated with the development
of cataracts (the relation between UV light and glaucoma is less clear). Recom-
mended preventive actions include use of sunscreen on the face and eyelids and
wearing sunglasses during exposure to direct sunlight.48

Hearing Loss. More than a third of adults older than 50 years—and 80% of
those 80 years and older—have hearing loss.42 However, this impairment, which
often contributes to emotional isolation and social withdrawal, is frequently
undetected. Unlike vision prerequisites for driving, there is no mandate for
widespread hearing testing, and many older adults avoid using hearing aids. The
USPSTF recommends screening adults 50 years of age and older.42 Hearing loss can
be accurately detected by a number of measures: a single-item screening test,
namely asking patients if they have difficulty hearing; multi-item questionnaires
such as the Hearing Handicap Inventory for the Elderly—Screening Version;49
handheld audiometers; the clinical “whisper test”; or the finger rub test.42 Aging is
the most important risk factor for hearing loss and presbycusis is the most common
age-related cause. In presbycusis, degenerating hair cells in the ear lead to gradually
progressive hearing loss, particularly for high-frequency sounds. Other risk factors
include congenital or familial hearing loss, syphilis, rubella, meningitis, diabetes,
recurring inner ear infections, exposure to ototoxic agents, frequent use of
headphones, and exposure to hazardous noise levels at work, leisure, or on the
battlefield. Hearing aids can improve hearing and quality of life, but are more likely
to be adopted by those who report hearing loss than those diagnosed clinically.
Consequently, in 2012, the USPSTF concluded that the evidence for screening
adults ≥age 50 years is insufficient, giving only a grade I recommendation.50

Oral Health. Clinicians should play an active role in promoting oral health:
up to 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.51,52 Nearly 50% of adults aged 30 years and above have some form or
periodontal disease, including 8.5% with severe disease.53 Risk factors for
periodontal disease include low income, male gender, smoking, diabetes, and
poor oral hygiene. Begin by carefully examining the mouth. Inspect the oral cavity
for decayed or loose teeth, inflammation of the gingiva (gingivitis), and signs of
periodontal disease such as bleeding, pus, recession of the gums, and bad breath.
Inspect the mucous membranes, the palate, the oral floor, and the surfaces of the
tongue for ulcers and leukoplakia, warning signs for oral cancer and HIV disease.

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To improve oral health counsel patients to adopt daily hygiene measures. Use of
fluoride-containing toothpastes reduces tooth decay, and brushing and flossing
retard periodontal disease by removing bacterial plaques. Urge patients to seek
dental care at least annually to receive the benefits of more specialized preventive
care such as scaling, planing of roots, and topical fluorides.

Address diet and tobacco use. As with children, adults should avoid excessive
intake of foods high in starches and refined sugars such as sucrose, which enhance
attachment and colonization of cariogenic bacteria. Urge patients to avoid use of
all tobacco products and to limit alcohol consumption to reduce risk of oral cancer.

Saliva cleanses and lubricates the mouth. Many medications reduce salivary flow,
increasing risk for tooth decay, mucositis, and gum disease from xerostomia,
especially for the elderly. If medications cannot be changed, recommend drink-
ing higher amounts of water and chewing sugarless gum. For those wearing
dentures, recommend removal and cleaning each night to reduce bacterial
plaque and risk of malodor. Regular massage of the gums relieves soreness and
pressure from dentures on the underlying soft tissue.

Oral Cancer. Over 40,000 cases of cancer of the oral cavity and orophar-
ynx were diagnosed in 2014, and more than 8,000 deaths were caused by these
cancers.54 Tobacco and alcohol account for about 75% of oral cavity cancers.55

Sexually transmitted infection with the human papillomavirus (HPV) affecting
the tonsils, oropharynx, and base of the tongue is an increasingly important
cause of oropharyngeal cancers, accounting for 80% to 95% of cases.56 Risk for
HPV infection is associated with age (highest prevalence among those aged 30 to
34 years and 60 to 64 years), male gender, a higher number of sexual partners,
sexual behaviors (oral sex), and cigarette smoking.57 The primary screening test
for these cancers is examination of the oral cavity; a critical preventive strategy
is HPV vaccination among age-eligible patients. However, in 2014, the USPSTF
concluded that there was insufficient evidence to routinely screen asymptomatic
adults (grade I recommendation).50 The American Dental Association recom-
mends that providers be aware of potentially malignant lesions during routine
oral examinations, particularly among patients who use tobacco or consume
excessive amounts of alcohol.58

Anatomy and Physiology and
Techniques of Examination

The Head

Anatomy and Physiology. Regions of the head take their names from the
underlying bones of the skull, for example, the frontal area. Knowing this
anatomy helps to locate and describe physical findings (see Fig. 7-2).

Two paired salivary glands lie near the mandible: the parotid gland, superficial to
and behind the mandible (both visible and palpable when enlarged), and the
submandibular gland, located deep to the mandible. Feel for the latter as you press

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ANATOMY AND PHYSIOLOGY

your tongue against your lower incisors. Its lobular surface can often be felt
against the tightened muscle. The openings of the parotid and submandibular
ducts are visible within the oral cavity (see p. 254).

The superficial temporal artery passes upward just in front of the ear, where it is
readily palpable. In many normal people, especially thin and elderly ones, the
tortuous course of one of its branches can be traced across the forehead.

Techniques of Examination. Because abnormalities under the hair are
easily missed, ask if the patient has noticed anything wrong with the scalp or
hair. Hairpieces and wigs should be removed. Examine the following.

The Hair. Note its quantity, distribution, texture, and any pattern of loss.
You may see loose flakes of dandruff.

The Scalp. Part the hair in several places and look for scaliness, lumps,
nevi, or other lesions.

Vertex of head

Parietal bone

Temporal
bone

Superficial
temporal
artery

Occipital
bone

Mastoid portion
of temporal bone

Mastoid process

Styloid process

Parotid
gland

Parotid
duct

Submandibular
gland

Submandibular
duct

Mandible

Maxilla

Zygomatic
bone

Nasal bone

Orbit

Frontal bone

F I G U R E 7 – 2 . Anatomy of the head.

Fine hair is seen in hyperthyroidism,
coarse hair in hypothyroidism. Tiny
white ovoid granules that adhere to

hairs may be nits (lice eggs).

Look for redness and scaling that may

indicate seborrheic dermatitis or psori-
asis; soft lumps that may be pilar cysts
(wens); and pigmented nevi that raise

concern of melanoma. See Table 6-6,
Brown Lesions—Melanoma and Its

Mimics, pp. 200–203.

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The Skull. Observe the general size and contour of the skull. Note any
deformities, depressions, lumps, or tenderness. Learn to recognize the irregu-
larities in a normal skull, such as those near the suture lines between the parietal
and occipital bones.

The Face. Note the patient’s facial expression and contours. Observe for
asymmetry, involuntary movements, edema, and masses.

The Skin. Observe the skin on the face and head, noting its color, pigmen-
tation, texture, thickness, hair distribution, and any lesions.

The Eyes

Anatomy and Physiology. Identify the
structures illustrated in Figure 7-3. Note that
the upper eyelid covers a portion of the iris but
does not normally overlay the pupil. The
opening between the eyelids is called the
palpebral fissure. The white sclera may look
somewhat buff-colored at its periphery. Do not
mistake this color for jaundice, which is a
deeper yellow.

The conjunctiva is a clear mucous membrane
with two easily visible components. The bulbar
conjunctiva covers most of the anterior eyeball,
adhering loosely to the underlying tissue. It
meets the cornea at the limbus. The palpebral
conjunctiva lines the eyelids. The two parts of
the conjunctiva merge in a folded recess that
permits movement of the eyeball.

Within the eyelids lie firm strips of connective
tissue called tarsal plates (Fig. 7-4). Each plate
contains a parallel row of meibomian glands,
which open on the lid margin. The levator pal-
pebrae, the muscle that raises the upper eyelid,
is innervated by the oculomotor nerve, CN III.
Smooth muscle, innervated by the sympa-
thetic nervous system, also contributes to lid
elevation.

See Table 7-5, Selected Facies, p. 272.

Acne is common in adolescents.
Hirsutism (excessive facial hair)
may appear in some women with

polycystic ovary syndrome.

Lateral canthus

Upper eyelid

Medial canthusPupilLimbusIris

Lower eyelid

Sclera covered
by conjunctiva

F I G U R E 7 – 3 . Anatomy of the eye.

Levator palpebrae

Bulbar
conjunctiva

Palpebral
conjunctiva

Cornea

Sclera
Eyelash

Meibomian
gland

Tarsal
plate

Limbus

F I G U R E 7 – 4 . Sagittal section of the anterior eye.

An enlarged skull may signify hydro-
cephalus or Paget disease of bone.
Palpable tenderness or bony step-offs

may be present after head trauma.

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A film of tear fluid protects the conjunctiva and
cornea from drying, inhibits microbial growth,
and gives a smooth optical surface to the cor-
nea. This fluid comes from the meibomian
glands, conjunctival glands, and lacrimal
gland. The lacrimal gland lies mostly within the
bony orbit, superior and lateral to the eyeball
(Fig. 7-5). The tear fluid spreads across the eye
and drains medially through two tiny holes
called lacrimal puncta. The tears then pass into
the lacrimal sac and on into the nose through
the nasolacrimal duct. You can easily find a
punctum atop the small elevation of the medial
lower lid medially. The lacrimal sac rests in a
small depression inside the bony orbit and is
not visible.

The eyeball is a spherical structure that focuses
light on the neurosensory elements within the
retina. The muscles of the iris control pupillary
size. Muscles of the ciliary body control the
thickness of the lens, allowing the eye to focus
on near or distant objects.

A clear liquid called aqueous humor fills the
anterior and posterior chambers of the eye.
Aqueous humor is produced by the ciliary body,
circulates from the posterior chamber through
the pupil into the anterior chamber, and drains
out through the canal of Schlemm. This circula-
tory system helps to control the pressure inside
the eye (Fig. 7-6).

Lacrimal gland
(within the bony orbit)

Puncta

Canaliculi

Lacrimal sac
(within the bony orbit)

Nasolacrimal
duct

F I G U R E 7 – 5 . Lacrimal gland, sac, and duct.

Canal of Schlemm

Ciliary body

Cornea

Posterior chamber

Lens

Anterior chamber
filled with aqueous
humor

Iris

F I G U R E 7 – 6 . Circulation of aqueous humor.

The posterior portion of the eye that is seen through the ophthalmoscope is often
called the optic fundus (Fig. 7-7). Structures here include the retina, choroid,
fovea, macula, optic disc, and retinal vessels. The optic nerve with its retinal ves-
sels enters the eyeball posteriorly, visible with an ophthalmoscope 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 area called the fovea. The roughly circular macula surrounds the fovea,
but has no discernible margins. You do not usually see the normal vitreous body,

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When a person is using both eyes, the two
visual fields overlap in an area of binocu-
lar vision. Laterally, vision is monocular
(Fig. 7-9).

a transparent mass of gelatinous material that fills the eyeball behind the lens and
helps to maintain the shape of the eye.

Visual Fields. A visual field is the
entire area seen by an eye when it looks at
a central point. Fields are conventionally
diagrammed on circles from the patient’s
point of view. The center of the circle rep-
resents the focus of gaze. The circumfer-
ence is 90° from the line of gaze. Each
visual field, shown by the white areas in
Figure 7-8, is divided into quadrants.
Note that the fields extend farthest on the
temporal sides. Visual fields are normally
limited by the brows above, the cheeks
below, and the nose medially. A lack of
retinal receptors at the optic disc produces
an oval blind spot in the normal field of
each eye, 15° temporal to the line of gaze.

Fovea

Macula

Vein
Artery

Physiologic
cup

Physiologic cup
in optic disc

Optic
disc

Optic
nerve

Central retinal
artery and vein

Retina

ScleraExtraocular
muscle

Vitreous body
Choroid

Iris

Pupil

Fovea

F I G U R E 7 – 7 . Cross-section of right eye showing the fundus as seen with an

ophthalmoscope.

Upper
temporal

Lower
temporal

Lower
nasal

Upper
nasal

Blind spot
90°

Blind spot

Normal visual
field

F I G U R E 7 – 8 . Visual field of left and right eyes.

Binocular vision

Monocular vision

F I G U R E 7 – 9 . Binocular field created by overlapping monocular fields.

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Visual Pathways. To see an image, light reflected from the target must
pass through the pupil and be focused on photoreceptors in the retina. The
image projected there is upside down and reversed right to left (Fig. 7-10). An
image from the upper nasal visual field thus strikes the lower temporal quadrant
of the retina.

Blind spot

Center of gaze

Object seen

Image on retina

Fovea

Optic nerve
A

A
O

F I G U R E 7 – 1 0 . Light pathway into the eye.

Nerve impulses, stimulated by light, are
conducted through the retina, optic
nerve (CN II), and optic tract on each
side, then on through a curving tract
called the optic radiation. This ends in
the visual cortex, a part of the occipital
lobe.

Pupillary Reactions. Pupillary size
changes in response to light and to the
effort of focusing on a near object.

The Light Reaction. A light beam
shining onto one retina causes pupillary
constriction in both that eye, termed the
direct reaction to light, and in the contra-
lateral eye, the consensual reaction to
light. The initial sensory pathways are
similar to those described for vision:
retina, optic nerve (CN II), and optic
tract, which diverges in the midbrain.
Impulses back to the constrictor mus-
cles of the iris of each eye are transmit-
ted through the oculomotor nerve,
CN III (Fig. 7-11).

Optic tract

To visual cortex

Oculomotor nerve

Optic nerve

To iris
(consensual
reaction)

Light

To iris
(direct reaction)

Key:
Blue––Sensory
Red––Motor

F I G U R E 7 – 1 1 . Pathways of the light reaction.

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The Near Reaction. In the near reaction,
when a person shifts gaze from a far object to
a near object, the pupils constrict (Fig. 7-12).
This response, like the light reaction, is
mediated by the oculomotor nerve (CN
III). Coincident with this pupillary con-
striction, but not part of it, are (1) conver-
gence of the eyes, a medial rectus
movement; and (2) accommodation, an
increased convexity of the lenses caused
by contraction of the ciliary muscles. In
accommodation the change in shape of
the lenses brings near objects into focus,
but is not visible to the examiner.

Autonomic Nerve Supply to the Eyes.
Fibers travelling in the oculomotor nerve (CN III)
and producing pupillary constriction are part of the
parasympathetic nervous system. The iris is also
supplied by sympathetic fibers. When these are
stimulated, the pupil dilates, and the upper eyelid
rises a little, as if from fear. The sympathetic path-
way starts in the hypothalamus and passes down
through the brainstem and cervical cord into the
neck. From there, it follows the carotid artery or its
branches into the orbit. A lesion anywhere along this
pathway may impair sympathetic effects that dilate
the pupil (Fig. 7-13).

F I G U R E 7 – 1 2 . The pupils constrict when the focus shifts to a

close object.

Temporal

Right Eye Left Eye

Nasal Temporal Nasal

Optic nerve

Optic chiasm
Optic tract

Optic
radiation

Visual
cortex

Visual
Fields

F I G U R E 7 – 1 3 . Visual pathways from retina to visual cortex.

Autonomic Stimulation

● Parasympathetics: Pupillary constriction
● Sympathetics: Pupillary dilation and raising of

upper eyelid (superior tarsal muscle)

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Extraocular Movements. The coordinated action of six muscles, the
four rectus and two oblique, control the eye. You can test the function of each
muscle and its CN innervation by asking the patient to move the eye in the
direction controlled by that muscle. There are six such cardinal directions, indi-
cated by the lines in Figure 7-14. When a person looks down and to the right,
for example, the right inferior rectus (CN III) is principally responsible for mov-
ing the right eye, whereas the left superior oblique (CN IV) is principally respon-
sible for moving the left eye. If one of these muscles is paralyzed, the eye will
deviate from its normal position in that direction of gaze and the eyes will no
longer appear conjugate, or parallel.

Superior
rectus (III)

Lateral
rectus
(VI)

Inferior
rectus (III)

Superior
rectus (III)

Lateral
rectus
(VI)

Inferior
rectus (III)

Superior
oblique (IV)

Medial
rectus (III)

Inferior
oblique (III)

F I G U R E 7 – 1 4 . Cardinal directions of gaze.

CN IV (trochlear nerve) damage, due to
head trauma, congenital causes, or

central lesions, causes dysfunction of

the superior oblique muscle, leading

to diplopia (double vision).

Techniques of Examination

Important Areas of Examination

● Visual acuity
● Visual fields
● Conjunctiva and sclera
● Cornea, lens, and pupils
● Extraocular movements
● Fundi, including: Optic disc and cup, retina, and retinal vessels

Visual Acuity. To test the acuity of central vision, use a well-lit Snellen eye
chart, if possible. Position the patient 20 feet from the chart. Patients who wear
glasses other than for reading should put them on. Ask the patient to cover one
eye with a card (to prevent looking through the fingers) and to read the smallest
line of print possible. Coaxing to attempt the next line may improve perfor-
mance. A patient who cannot read the largest letter should be positioned closer
to the chart; note the intervening distance. Identify the smallest line of print
where the patient can identify more than half the letters. Record the visual acuity
designated at the side of this line, along with use of glasses, if any. Visual acuity
is expressed as two numbers (e.g., 20/30): the first indicates the distance of the
patient from the chart, and the second, the distance at which a normal eye can
read the line of letters.59

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. The

larger the second number, the worse

the vision. “20/40 corrected” means the

patient could read the 20/40 line with

glasses (a correction).

Myopia (nearsightedness) causes
focusing problems for distance vision.

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Testing near vision with a hand-held card can help identify the need for reading
glasses or bifocals in patients older than 45 years. You can also use this card to
test visual acuity at the bedside. Held 14 inches from the patient’s eyes, the card
simulates a Snellen chart.

If you have no charts, screen visual acuity with any available print. If patients
cannot read even the largest letters, test their ability to count your upraised fin-
gers and distinguish light (such as your flashlight) from dark.

Visual Fields by Confrontation. Confrontation testing of the visual
fields is a valuable screening technique for detection of lesions in the anterior
and posterior visual pathway. Recent studies recommend combining two tests
to achieve the best results: the static finger wiggle test and the kinetic red target
test.60,61 Sensitivity and specificity of the two tests, when performed rigor-
ously, compared to automated perimetry, is 78% and 90%; diagnostic accu-
racy improves with higher density and severity of field defects, irrespective of
diagnosis.60 Nevertheless, even relatively dense quadrantic or hemianopic
visual field defects can be missed by confrontation screening tests. A formal-
ized automated perimetry test such as the Humphrey visual field performed
by an ophthalmologist is needed to make a definitive diagnosis of a visual field
defect.

Static Finger Wiggle Test.
Position yourself about an
arm’s length away from the
patient. Close one eye and
have the patient cover the
opposite eye while staring
at your open eye. So, for
example, when the patient
covers the left eye, to test
the visual field of the
patient’s right eye you
should cover your right
eye to mimic the patent’s
field of view. Place your
hands about 2 feet apart
out of the patient’s view,
roughly lateral to the
patient’s ears (Fig. 7-15).

Presbyopia causes focusing problems
for near vision, found in middle-aged

and older adults. A presbyopic person

often sees better when the card is

farther away.

In the United States, a person is usu-

ally considered legally blind when
vision in the better eye, corrected by

glasses, is 20/200 or less. Legal blind-
ness also results from a constricted

field of vision: 20° or less in the better
eye.

Refer patients with suspected visual

field defects for ophthalmology eval-

uation. Causes of anterior pathway

defects include glaucoma, optic neu-
ropathy, optic neuritis, and glioma.
Posterior pathway defects include

stroke and chiasmal tumors.62

F I G U R E 7 – 1 5 . Static finger wiggle test. F I G U R E 7 – 1 6 . Visual field defects.

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While in this position, wiggle your fingers and slowly bring your moving fingers
forward into the patient’s center of view. Ask the patient to tell you as soon as
he or she sees your finger movement. Test each clock hour, or at least each
quadrant. Test each eye individually and record the extent of visits in each area.
Note any abnormal “field cuts” (Figs. 7-16 and 7-17).

Kinetic Red Target Test. Facing the patient, move a 5-mm red-topped pin
inward from beyond the boundary of each quadrant along a line bisecting the
horizontal and vertical meridians. Ask the patient when the pin first appears to
be red.

Position and Alignment of the Eyes. Stand in front of the patient and
survey the eyes for position and alignment. If one or both eyes seem to protrude,
assess them from above (see p. 264).

Eyebrows. Inspect the eyebrows, noting their fullness, hair distribution,
and any scaliness of the underlying skin.

Eyelids. Note the position of the lids in relation to the eyeballs. Inspect for
the following:

â–  Width of the palpebral fissures

â–  Edema of the lids

â–  Color of the lids

â–  Lesions

â–  Condition and direction of the eyelashes

Covered

RIGHTLEFT

RIGHTLEFT

F I G U R E 7 – 1 7 . A left homonymous

hemianopsia may be established.

Review these patterns in Table 7-6,

Visual Field Defects, p. 273.

As an example, when the patient’s left

eye repeatedly does not see your fin-

gers until they have crossed the line

of gaze, a left homonymous hemianop-
sia is present. It is diagrammed from
the patient’s viewpoint.

An enlarged blind spot occurs in con-

ditions affecting the optic nerve such

as glaucoma, optic neuritis, and papill-
edema.23

Abnormalities include esotropia
(inward deviation) or exotropia (out-
ward deviation) of the eyes and also

abnormal protrusion in Graves disease
or ocular tumors.

Scaliness occurs in seborrheic dermatitis,
lateral sparseness in hypothyroidism.

See Table 7-7, Variations and Abnor-

malities of the Eyelids, p. 274.

Upslanting palpebral fissures are

noted in Down syndrome.

Red inflamed lid margins occur in

blepharitis, often with crusting.

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â–  Adequacy of eyelid closure. Look for this especially when the eyes are unusu-
ally prominent, when there is facial paralysis, or when the patient is uncon-
scious.

Lacrimal Apparatus. Briefly inspect the regions of the lacrimal gland and
lacrimal sac for swelling.

Look for excessive tearing or dryness of the eyes. Assessment of dryness may
require special testing by an ophthalmologist. To test for nasolacrimal duct
obstruction, see p. 264.

Conjunctiva and Sclera. Ask
the patient to look up as you depress
both lower lids with your thumbs,
exposing the sclera and conjunctiva
(Figs. 7-18 and 7-19). Inspect the
sclera and palpebral conjunctiva for
color. Note the vascular pattern
against the white scleral background.
The slight vascularity of the sclera in
Figures 7-18 and 7-20 is normal and
present in most people.

Look for any nodules or swelling
(Fig. 7-21).

If you need a fuller view of the eye,
rest your thumb and finger on the
bones of the cheek and brow, respec-
tively, and spread the lids (Fig. 7-20).

Ask the patient to look to each side
and down. This technique gives you
a good view of the sclera and bulbar
conjunctiva, but not of the palpebral
conjunctiva of the upper lid. For
this, you need to evert the lid (see
pp. 264–265).

Failure of the eyelids to close exposes

the corneas to serious damage.

See Table 7-8, Lumps and Swellings in

and Around the Eyes, p. 275.

Excessive tearing may be from

increased production, caused by con-
junctival inflammation or corneal irri-
tation, or impaired drainage, caused
by ectropion (p. 274) and nasolacrimal
duct obstruction. Dryness from
impaired secretion is seen in Sjögren
syndrome.

F I G U R E 7 – 1 8 . Inspect the sclera

and conjunctiva.

F I G U R E 7 – 1 9 . A yellow sclera

indicates jaundice.

F I G U R E 7 – 2 0 . Obtain a fuller view

of the eye.

F I G U R E 7 – 2 1 . Local redness is

from nodular episcleritis.

For comparisons, see Table 7-3, Red

Eyes, p. 270.

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Cornea and Lens. With oblique lighting, inspect the cornea of each eye
for opacities. Note any opacities in the lens that may be visible through the pupil.

Iris. 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 cres-
centic shadow on the medial side of the iris (Fig. 7-22). Because the iris is nor-
mally fairly flat and forms a relatively open angle with the cornea, this lighting
casts no shadow.

See Table 7-9, Opacities of the Cornea

and Lens, p. 276.

Light

Light

F I G U R E 7 – 2 2 . Light each eye from the side for inspection.

Occasionally, the iris bows abnormally

far forward, forming a very narrow

angle with the cornea. The light then

casts a crescentic shadow as shown

here.

This narrow angle increases the risk

for acute narrow-angle glaucoma a
sudden increase in IOP when drainage

of the aqueous humor is blocked

(see left upper diagram).

In open-angle glaucoma, the common
form of glaucoma, the normal spatial

relation between iris and cornea is

preserved and the iris is fully lit.

Pupils. In a dim light, inspect the size, shape, and symmetry of both pupils.
Measure the pupils with a card showing black circles of varying sizes, shown
below, and test the light reaction. Note if the pupils are large (>5 mm), small
(<3 mm), or unequal (Fig. 7-23).

1 2 3 4 5 6 7 mm

F I G U R E 7 – 2 3 . Pupillary sizes.

Miosis refers to constriction of the
pupils, mydriasis to dilation.

Simple anisocoria, or a difference in pupillary diameter of 0.4 mm or greater without
a known pathologic cause, is visible in approximately 35% of healthy people, and
rarely exceeds 1 mm.63 Simple anisocoria is considered benign if it is equal in dim
and bright light, and there is brisk pupillary constriction to light (the light reaction).

The Light Reaction. In dim light, test the pupillary reaction to light. Ask the
patient to look into the distance, and shine a bright light obliquely into each
pupil in turn. Both the distant gaze and the oblique lighting help to prevent a
near reaction. Look for:

â–  The direct reaction (pupillary constriction in the same eye)

â–  The consensual reaction (pupillary constriction in the opposite eye)

Compare benign anisocoria with Horner
syndrome, oculomotor nerve paralysis,
and tonic pupil. See Table 7-10, Pupillary
Abnormalities, p. 277.

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Always darken the room and use a bright light before deciding that a light reac-
tion is abnormal or absent.

The Near Reaction. If the reaction to light is impaired or questionable, test the
near reaction in both dim and normal light. Testing one eye at a time makes it
easier to concentrate on pupillary responses, without the distraction of EOM.
Hold your finger or pencil about 10 cm from the patient’s eye. Ask the patient to
look alternately at it and into the distance directly behind it. Watch for pupillary
constriction with near effort and convergence of the eyes. The third component
of the near reaction, accommodation of the lens that brings the near object into
focus, is not visible.

Compare the normal light reaction and near reaction of benign anisocoria with
the constriction abnormalities of tonic pupil and oculomotor nerve (CN III) paraly-
sis and the dilatation abnormalities of Horner syndrome and Argyll Robertson
pupils.

Extraocular Muscles. Standing about 2 feet directly in front of the
patient, shine a light into the patient’s eyes and ask the patient to look at it.
Inspect the light reflection in the corneas. They should be visible slightly nasal to the
center of the pupils (Fig. 7-24).

Testing the near reaction is helpful in

diagnosing Argyll Robertson and tonic
(Adie) pupils (see p. 277).

F I G U R E 7 – 2 4 . Inspect light reflection in the corneas.

Asymmetry of the corneal reflections

indicates a deviation from normal

ocular alignment. A temporal light

reflection on one cornea, for example,

indicates a nasal deviation of that eye.

A cover–uncover test may reveal a slight or latent muscle imbalance not otherwise
seen; this is particularly useful in examining children (see p. 278).

Now assess the EOMs, looking for:

â–  The normal conjugate movements of the eyes in each direction. Note any devi-
ation from normal, or dysconjugate gaze.

â–  Nystagmus, a fine rhythmic oscillation of the eyes. A few beats of nystagmus
on extreme lateral gaze are normal. If you see this, bring your finger in to
within the field of binocular vision and look again.

â–  Lid lag as the eyes move from up to down.

See Table 7-11, Dysconjugate Gaze,

p. 278.

Sustained nystagmus within the bin-

ocular field of gaze is seen in congeni-

tal disorders, labyrinthitis, cerebellar

disorders, and drug toxicity. See

Table 17-7, Nystagmus, pp. 785–786.

In the lid lag of hyperthyroidism, a rim
of sclera is visible above the iris with

downward gaze.

E X A M P L E S O F A B N O R M A L I T I E S

See Table 7-10, Pupillary Abnormali-

ties, p. 277.

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ANATOMY AND PHYSIOLOGY

1

2

3

4

5

6

F I G U R E 7 – 2 5 . Test extraocular movements.

Test the Six EOMs. Ask the patient to follow your finger or pencil as you sweep
through the six cardinal directions of gaze. Making a wide H in the air, lead the
patient’s gaze (Fig. 7-25):

1. to the patient’s extreme right,

2. to the right and upward, and

3. down on the right; then

4. without pausing in the middle, to the extreme left,

5. to the left and upward, and

6. down on the left.

Pause during upward and lateral gaze to detect nystag-
mus. Move your finger or pencil at a comfortable dis-
tance from the patient. Because middle-aged or older
adults may have difficulty focusing on near objects,
increase this distance. Some patients move their heads
to follow your finger. If necessary, hold the head in the
proper midline position.

If you suspect lid lag or hyperthyroidism, ask the patient
to follow your finger again as you move it slowly from
up to down in the midline. The upper eyelid should
overlap the iris slightly throughout this movement as
shown in Figure 7-27. Figure 7-28 shows proptosis.

In paralysis of the left CN VI, illustrated

above, the eyes are conjugate in right

lateral gaze but not in left lateral gaze.

LOOKING RIGHT

LOOKING LEFT

F I G U R E 7 – 2 6 . CN VI paralysis.

F I G U R E 7 – 2 7 . Normal

upper lid overlap.

F I G U R E 7 – 2 8 . Visible rim

of sclera caused by proptosis.

Note the rim of sclera from proptosis,
an abnormal protrusion of the eye-

balls in hyperthyroidism, leading to a
characteristic “stare” on frontal gaze. If

unilateral, consider an orbital tumor or
retrobulbar hemorrhage from trauma.

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Finally, if the near reaction has not already been tested, test for convergence. Ask
the patient to follow your finger or pencil as you move it in toward the bridge of
the nose. The converging eyes normally follow the object to within 5 cm to 8 cm
of the nose (Fig. 7-29).

F I G U R E 7 – 2 9 . Test for convergence.

Convergence is poor in hyperthyroidism.

Ophthalmoscopic Examina-
tion. In general health care, exam-
ine your patients’ eyes without
dilating their pupils, which can
obscure important neurologic find-
ings. Therefore, your view is limited
to the posterior structures of the ret-
ina. To see more peripheral struc-
tures, to evaluate the macula well, or
to investigate unexplained visual loss,
consider referral to ophthalmologists
for pupillary dilatation with mydri-
atic drops.

This section describes how to use the
traditional ophthalmoscope (Fig.
7-30). Of note, some medical offices
now use a PanOptic ophthalmoscope.
The PanOptic ophthalmoscope allows clinicians to view the retina, even when
the pupils are undilated. It provides a five-fold greater view of the fundus than
the traditional ophthalmoscope, enables a 25° field of view, and increases the
examining distance between the patient and the clinician. Since most clinical
settings still use the traditional ophthalmoscope, emphasized here.

Using the ophthalmoscope to visualize the fundus is one of the most challenging
skills of physical examination, and one of the most critical when assessing head-
ache and changes in mental status. With feedback and dedicated practice of
proper technique, the fundus, optic disc, and retinal vessels will come into focus.
Remove your glasses unless you have marked nearsightedness or severe astigma-
tism, or your refractive error makes it difficult to see the fundi.

Review the components of the ophthalmoscope pictured above and follow the
steps for using the ophthalmoscope. With commitment and repetition, your
examination skills will improve over time.

Contraindications for mydriatic drops

include (1) head injury and coma,

since continuing observations of

pupillary reactions are essential, and

(2) any suspicion of narrow-angle

glaucoma.

Aperture

Indicator of
diopters

Lens disc

F I G U R E 7 – 3 0 . Parts of the

ophthalmoscope.

E X A M P L E S O F A B N O R M A L I T I E S

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Steps for Using the Ophthalmoscope

● Darken the room. 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 electri-

cal 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 so

that you can turn the disc to focus the lens when you examine the fundus.
● Hold the ophthalmoscope in your right hand and use your right eye to exam-

ine the patient’s right eye; hold it in your left hand and use your left eye to
examine the patient’s left eye. This keeps you from bumping the patient’s
nose and gives you more mobility and closer range for visualizing the fundus.

With practice, you will become accustomed to using your nondominant eye.
● Hold the ophthalmoscope firmly braced against the medial aspect of your bony

orbit, with the handle tilted laterally at about 20° slant from the vertical. Check
to make sure you can see clearly through the aperture. Instruct the patient to
look slightly up and over your shoulder at a point directly ahead on the wall.

● Place yourself about 15 inches away from the patient and at an angle 15° lat-
eral to the patient’s line of vision. Shine the light beam on the pupil and look
for the orange glow in the pupil—the red reflex. Note any opacities interrupt-
ing the red reflex.

Examiner at 15-degree angle from patient’s line of vision, eliciting red reflex.

● Now place the thumb of your other hand across the patient’s eyebrow, which
steadies your examining hand. Keeping the light beam focused on the red

reflex, move in with the ophthalmoscope on the 15° angle toward the pupil
until you are very close to it, almost touching the patient’s eyelashes and the

thumb of your other hand.
● Try to keep both eyes open and relaxed, as if gazing into the distance, to help

minimize any fluctuating blurriness as your eyes attempt to accommodate.
● You may need to lower the brightness of the light beam to make the examina-

tion more comfortable for the patient, avoid hippus (spasm of the pupil),
and improve your observations.

*Some clinicians like to use the large round beam for large pupils, and the small round beam for small

pupils. The other beams are rarely helpful. The slitlike beam is sometimes used to assess elevations or

concavities in the retina, the green (or red-free) beam to detect small red lesions, and the grid to make

measurements. Ignore the last three lights and practice with the large or small round white beam.

Absence of a red reflex suggests an
opacity of the lens (cataract) or, possi-

bly, the vitreous (or even an artificial

eye). Less commonly, a detached ret-
ina or, in children, a retinoblastoma
may obscure this reflex.

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Now you are ready to inspect the optic disc and the retina. The optic disc is a
round, yellow-orange to creamy pink structure with a pink neuroretinal rim and
central depression that often takes practice to locate. The ophthalmoscope mag-
nifies the normal disc and retina about 15 times and the normal iris about 4
times. The optic disc actually measures about 1.5 mm. Follow the next steps for
this important segment of the physical examination.

When the lens has been removed sur-

gically, its magnifying effect is lost.

Retinal structures then look much

smaller than usual, and you can see a

much larger expanse of the fundus.

Steps for Examining the Optic Disc
and the Retina

The Optic Disc
● First, locate the optic disc. Look for the round yellowish-orange structure

described above, or follow a blood vessel centrally until it enters the disc. The

vessel size will help you. The vessel size becomes progressively larger at each

branch point as you approach the disc.

Artery

Vein

Optic disc

Physiologic cup

The optic disc and fundus.

● Now, bring the optic disc into sharp focus by adjusting the lens of your ophthal-
moscope. If both you and the patient have no refractive errors, the retina

should be in focus at 0 diopters.
● If structures are blurred, rotate the lens disc until you find the sharpest

focus.

For example, if the patient is myopic (nearsighted), rotate the lens disc
counterclockwise to the minus diopters; in a hyperopic (farsighted) patient,
move the disc clockwise to the plus diopters. You can correct your own
refractive error in the same way.

● Inspect the optic disc. Note the following features:
● The sharpness or clarity of the disc outline. The nasal portion of the disc mar-

gin may be somewhat blurred, a normal finding.
● The color of the disc, normally yellowish orange to creamy pink. White or

pigmented crescents may ring the disc, a normal finding.
● The size of the central physiologic cup, if present. It is usually yellowish white.

The horizontal diameter is usually less than half the horizontal

diameter of the disc.
● The comparative symmetry of the eyes and findings in the fundi.

In a refractive error, light rays from a
distance do not focus on the retina.

In myopia, they focus anterior to the
retina, in hyperopia, posterior to it.
Retinal structures in a myopic eye

look larger than normal.

See Table 7-12, Normal Variations of

the Optic Disc, p. 279, and Table 7-13,

Abnormalities of the Optic Disc, p. 280.

An enlarged cup suggests chronic
open-angle glaucoma.

(continued )

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Steps for Examining the Optic Disc
and the Retina (continued )

The Importance of Detecting Papilledema
Swelling of the optic disc and anterior bulging of the physiologic cup suggest
papilledema (Fig. 7-31), which is associated with increased intracranial pressure.
This pressure is transmitted to the optic nerve, causing stasis of axoplasmic flow,

intra-axonal edema, and swelling of the optic nerve head. Papilledema signals

serious disorders of the brain, such as meningitis, subarachnoid hemorrhage,

trauma, and mass lesions, so searching for this important disorder is a priority dur-

ing all your funduscopic examinations (see technique as described on prior page).

Inspect the fundus for spontaneous venous pulsations (SVPs), rhythmic varia-
tions in the caliber of the retinal veins as they cross the fundus (narrower in

systole; wider in diastole), present in 90% of normal patients.

The Retina—Arteries, Veins, Fovea, and Macula
● Inspect the retina, including arteries and veins as they extend to the periphery,

arteriovenous crossings, the fovea, and the macula. Distinguish arteries from

veins based on the features listed below.

Arteries Veins
Color Light red Dark red

Size Smaller (2/3 to 3/4 the

diameter of veins)

Larger

Light reflex (reflection) Bright Inconspicuous or absent

● Follow the vessels peripherally in each direc-
tion, noting their relative sizes and the char-
acter of the arteriovenous crossings.

Identify any lesions of the surrounding

retina and note their size, shape, color, and
distribution. As you search the retina, move
your head and instrument as a unit, using
the patient’s pupil as an imaginary fulcrum.
At first, you may lose your view of the retina

because your light falls out of the pupil, but

you will improve with practice.

Lesions of the retina can be measured in

terms of “disc diameters” from the optic

disc.

F I G U R E 7 – 3 1 . Papilledema.

Loss of SVPs occurs with high intracra-

nial pressures (above 190 mm H2O)

that change the pressure gradient

between cerebral spinal fluid pressure

and intraocular pulse pressure in the

optic disc. Other causes include glau-
coma and retinal vein occlusion.64,65

1
4

2

5

3

Sequence of inspection from

disc to macula (left eye).

See Tables 7-14 to 7-18 for informa-

tion on retinal arteries and AV cross-

ings, spots and streaks in the fundi,

normal and hypertensive retinopathy,

diabetic retinopathy, and light-

colored spots in the fundi.

Note the irregular patches, seen in

diabetic and hypertensive retinopathy,

between 11 and 12 o’clock, 1 to 2 disc

diameters from the disc. Each measures

about ½ by ½ disc diameters.

F I G U R E 7 – 3 2 . Cotton-wool patches.

(continued )

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Macular degeneration is an important
cause of poor central vision in older

adults. Types include dry atrophic
(more common but less severe) and

wet exudative, or neovascular. Cellular
debris, called drusen, may be hard and
sharply defined, as seen in Figure 7-33,

or soft and confluent with altered pig-

mentation (see p. 285).

F I G U R E 7 – 3 3 . Hard drusen.

(Photo from Tasman W, Jaeger E (eds). The Wills Eye

Hospital Atlas of Clinical Ophthalmology, 2nd ed.

Philadelphia, Lippincott Williams & Wilkins, 2001.)

Vitreous floaters are dark specks or

strands seen between the fundus and

the lens. Cataracts are densities in the

lens (see p. 276).

Steps for Examining the Optic Disc
and the Retina (continued )

● Inspect the fovea and surrounding macula. Direct your light beam laterally or
ask the patient to look directly into the light. In younger people, the tiny

bright reflection at the center of the fovea helps to orient you; shimmering

light reflections in the macular area are common.

Optic disc

Macula

Fovea

Light
reflection

Structures of the left fundus.

● Inspect the anterior structures. Look for opacities in the vitreous or lens. Rotate
the lens disc progressively to diopters of around +10 or +12, so you can focus
on the more anterior structures in the eye.

The Ear

Anatomy and Physiology. The ear has three
compartments: the external ear, the middle ear, and the
inner ear.

The External Ear. The external ear comprises the
auricle and ear canal. The auricle consists chiefly of cartilage
covered by skin and has a firm elastic consistency. Its prom-
inent curved outer ridge is the helix. Parallel and anterior to
the helix is another curved prominence, the antihelix. Inferi-
orly is the fleshy projection of the earlobe, or lobule. The ear
canal opens behind the tragus, a nodular protrusion that
points backward over the entrance to the canal (Fig. 7-34).

The ear canal curves inward and is approximately 24 mm
long. Cartilage encases its outer two thirds. In this segment,
the skin is hairy and contains glands that produce cerumen
(wax). The inner third of the canal is surrounded by bone

Helix

Antihelix

Entrance
to ear
canal

Tragus

Lobule

F I G U R E 7 – 3 4 . Anatomy of the external ear.

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and lined by thin, hairless skin. Pressure on this latter area causes pain—a point
to remember when you when you examine the ear. At the end of the ear canal
lies the lateral tympanic membrane, or eardrum, marking the medial limit of the
external ear. The external ear captures sound waves for transmission into the
middle and inner ear (Fig. 7-35).

Incus

Ossicles

Malleus Stapes

Cochlear
nerve (CN VIII)

Semicircular
canals

Cochlea

Eustachian tube

Middle ear cavity

Tympanic
membrane

Bone
Mastoid process

Cartilage

Ear canal

Auricle

F I G U R E 7 – 3 5 . Anatomy of middle and inner ear.

Behind and below the ear canal is the mastoid portion of the temporal bone.
The lowest portion of this bone, the mastoid process, is palpable behind the
lobule.

The Middle Ear. In the air-filled middle ear, the ossicles—the malleus, the
incus, and the stapes—transform sound vibrations into mechanical waves for the
inner ear. The proximal end of the eustachian tube connects the middle ear to
the nasopharynx.

Two of the ossicles are visible through the tym-
panic membrane, and are angled obliquely and
held inward at its center by the malleus (Fig. 7-36).
Find the handle and the short process of the mal-
leus, the two chief landmarks. From the umbo,
where the eardrum meets the tip of the malleus, a
light reflection called the cone of light fans down-
ward and anteriorly. Above the short process lies a
small portion of the eardrum called the pars flac-
cida. The remainder of the drum is the pars tensa.
Anterior and posterior malleolar folds, which
extend obliquely upward from the short process,
separate the pars flaccida from the pars tensa, but

Pars flaccida

Incus

Pars tensa
Umbo

Cone of light

Handle of malleus

Short process of malleus

F I G U R E 7 – 3 6 . Right eardrum.

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are usually invisible unless the eardrum is retracted. A second ossicle, the incus,
can sometimes be seen through the drum.

The Inner Ear. The inner ear includes the cochlea, the semicircular canals,
and the distal end of the auditory nerve, also known as the vestibulocochlear nerve,
or CN VIII. Movements of the stapes vibrate the perilymph in the labyrinth of the
semicircular canals and the hair cells and endolymph in the ducts of the cochlea,
producing electrical nerve impulses transmitted by the auditory nerve to the
brain.

Much of the middle ear and all of the inner ear are inaccessible to direct examina-
tion. Assess their condition by testing auditory function.

Hearing Pathways. The first part of the hearing pathway, from the exter-
nal ear through the middle ear, is known as the conductive phase. The second part
of the pathway, involving the cochlea and cochlear nerve, is the sensorineural
phase (Fig. 7-37).

Sensorineural

Bone conduction

Air conduction

F I G U R E 7 – 3 7 . Hearing pathways.

Air conduction (AC) describes the normal first phase in the hearing pathway.
An alternative pathway, known as bone conduction (BC), bypasses the external
and middle ear and is used for testing purposes. A vibrating tuning fork,
placed on the head, sets the bone of the skull into vibration and stimulates
the cochlea directly. In those with normal hearing, AC is more sensitive than
BC (AC > BC).

Equilibrium. The labyrinth of three semicircular canals in the inner ear
senses the position and movements of the head and helps maintain balance.

Techniques of Examination

The Auricle. Inspect the auricle and surrounding tissue for deformities,
lumps, or skin lesions.

Hearing disorders of the external and

middle ear cause conductive hearing
loss. External ear causes include ceru-
men impaction, infection (otitis
externa), trauma, squamous cell carci-
noma, and benign bony growths such
as exostoses or osteomas. Middle ear
disorders include otitis media, congen-
ital conditions, cholesteatomas and
otosclerosis, tumors, and perforation of
the tympanic membrane.

Disorders of the inner ear cause sen-
sorineural hearing loss from congeni-
tal and hereditary conditions,

presbycusis, viral infections such as
rubella and cytomegalovirus, Ménière
disease, noise exposure, ototoxic drug
exposure, and acoustic neuroma.44

See Table 7-19, Lumps on or Near the

Ear, p. 286.

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If ear pain, discharge, or inflammation is present, move the auricle up and down,
press the tragus, and press firmly just behind the ear.

Ear Canal and Drum. To see the
ear canal and drum, use an otoscope with
the largest ear speculum that inserts eas-
ily into the canal. Position the patient’s
head so that you can see comfortably
through the otoscope. To straighten the
ear canal, grasp the auricle firmly but
gently and pull it upward, backward, and
slightly away from the head (Fig. 7-38).

Holding the otoscope handle between your thumb and fingers, brace your hand
against the patient’s face (Fig. 7-39). Your hand and instrument can then follow
unexpected movements by the patient. (If you are uncomfortable switching
hands for the left ear, as shown in Figure 7-40, you may reach over that ear to
pull it up and back with your left hand and hold the otoscope steady with your
right hand as you gently insert the speculum.)

Insert the speculum gently into the ear canal, directing it somewhat down and
forward and through the hairs, if any.

Movement of the auricle and tragus

(the “tug test”) is painful in acute otitis
externa (inflammation of the ear
canal), but not in otitis media (inflam-
mation of the middle ear). Tenderness

behind the ear occurs in otitis media.

F I G U R E 7 – 3 8 . Straighten the ear

canal to insert the otoscope.

Nontender nodular swellings covered

by normal skin deep in the ear canals

suggest exostoses (Fig. 7-41). These
are nonmalignant overgrowths which

may obscure the drum.

F I G U R E 7 – 3 9 . Brace your hand

and gently insert the speculum.

F I G U R E 7 – 4 0 . Insert the

speculum at a slight downward angle.

F I G U R E 7 – 4 1 . Exostosis.

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Inspect the ear canal, noting any discharge, foreign bodies, redness of the skin, or
swelling. Cerumen, which varies in color and consistency from yellow and flaky
to brown and sticky or even to dark and hard, may wholly or partly obscure your
view.

Pars flaccida

Incus

Pars tensa
Umbo

Cone of light

Handle of malleus

Short process of malleus

F I G U R E 7 – 4 2 . Anatomy of the right eardrum.

In acute otitis externa (Fig. 7-43), the
canal is often swollen, narrowed, moist,

pale, and tender. It may be reddened.

F I G U R E 7 – 4 3 . Acute otitis externa.

Identify the handle of the malleus, noting its position, and inspect the short process
of the malleus.

Gently move the speculum so that you can see as much of the drum as possible,
including the pars flaccida superiorly and the margins of the pars tensa. Look for
any perforations. The anterior and inferior margins of the drum may be obscured
by the curving wall of the ear canal.

Mobility of the eardrum can be evaluated with a pneumatic otoscope (see
p. 870).

Testing Auditory Acuity—Whispered Voice Test. To begin screening,
ask the patient “Do you feel you have a hearing loss or difficulty hearing?” If the
patient reports hearing loss, proceed to the whispered voice test.

The whispered voice test is a reliable screening test for hearing loss if the exam-
iner uses a standard method of testing and exhales before whispering. For best
results, follow the steps on the next page.

In chronic otitis externa, the skin of the
canal is often thickened, red, and itchy.

Look for the red bulging drum of acute

purulent otitis media30 and for the amber
drum of a serous effusion. See Table 7-20,

Abnormalities of the Eardrum, pp. 287–

288 and Table 18-7, Abnormalities of the

Eyes, Ears, and Mouth, p. 916.

Inspect the eardrum, noting its color and contour (Fig. 7-42). The cone of light—
usually easy to see—helps to orient you.

An unusually prominent short process

and a prominent handle that looks more

horizontal suggest a retracted drum.

A serous effusion, a thickened drum,

or purulent otitis media may decrease
mobility. If there is a perforation,

there will be no mobility.

Patients who answer “yes” are twice as

likely to have a hearing deficit; for

patients who report normal hearing

the likelihood of moderate to severe

hearing impairment is only 0.13.66

Sensitivity is 90% to 100% and speci-

ficity 70% to 87%.66–69 This test

detects significant hearing loss of

greater than 30 decibels. A formal

hearing test is still the gold standard.

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Testing for Conductive Versus Neurosensory Hearing Loss: Tuning
Fork Tests. For patients failing the whispered voice test, the Weber and Rinne
fork tests may help determine if the hearing loss is conductive or sensorineural
in origin. However, their precision, or test–retest reproducibility, and their accu-
racy compared to air–bone gap reference standards have been questioned.66

To conduct these tests, make sure the
room is quiet, and use a tuning fork of
512 Hz. These frequencies fall within
the range of conversational speech,
namely 500 to 3,000 Hz and between
45 and 60 decibels.

Set the fork into light vibration by
briskly stroking it between the thumb
and index finger ( ) or by tapping it
on your forearm just in front of your
elbow.

â–  Test for lateralization (Weber test).
Place the base of the lightly vibrat-
ing tuning fork firmly on top of the
patient’s head or on the midfore-
head (Fig. 7-44).

Whispered Voice Test for Auditory Acuity

● Stand 2 feet behind the seated patient so that the patient cannot read your

lips.68

● Occlude the nontest ear with a finger and gently rub the tragus in a circular

motion to prevent transfer of sound to the nontest ear.
● Exhale a full breath before whispering to ensure a quiet voice.
● Whisper a combination of three numbers and letters, such as 3-U-1. Use a

different number/letter combination for the other ear.
● Interpretation:

● Normal: Patient repeats initial sequence correctly.
● Normal: Patient responds incorrectly, so test a second time with a different

number/letter combination; patient repeats at least three out of the possi-

ble six numbers and letters correctly.
● Abnormal: Four of the six possible numbers and letters are incorrect. Con-

duct further testing by audiometry. (The Weber and Rinne tests are less

accurate and precise.)66

Note also that tuning fork tests do not

distinguish normal hearing from bilat-

eral sensorineural loss or from mixed

conductive–sensorineural loss. Sensitiv-

ity of the Weber test is about 55%; speci-

ficity for sensorineural loss is about

79%, and for conductive loss, 92%. Sen-

sitivity and specificity of the Rinne test

are 60% to 90% and 95% to 98%.70

Note that older adults with presby-
cusis have higher frequency hearing
loss, making them more likely to miss

consonants, which have higher fre-

quency sounds than vowels.

F I G U R E 7 – 4 4 . Weber test.

In unilateral conductive hearing loss,
sound is heard in (lateralized to) the

impaired ear. Explanations include

otosclerosis, otitis media, perforation
of the eardrum, and cerumen. See

Table 7-21, Patterns of Hearing Loss,

p. 289.

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Ask where the patient hears the sound: on one side or both sides? Normally, the
vibration is heard in the midline or equally in both ears. If nothing is heard, try
again, pressing the fork more firmly on the head. Restrict this test to patients with
unilateral hearing loss since patients with normal hearing may lateralize, and
patients with bilateral conductive or sensorineural deficits will not lateralize.

â–  Compare AC and BC (Rinne test). Place the base of a lightly vibrating tuning fork
on the mastoid bone, behind the ear and level with the canal (Fig. 7-45). When
the patient can no longer hear the sound, quickly place the fork close to the ear
canal and ask if the patient hears a vibration (Fig. 7-46). Here, the “U” of the
fork should face forward, which maximizes sound transmission for the patient.
Normally, the sound is heard longer through air than through bone (AC > BC).

In unilateral sensorineural hearing
loss, sound is heard in the good ear.

F I G U R E 7 – 4 5 . Test bone conduction. F I G U R E 7 – 4 6 . Test air conduction.

In conductive hearing loss, sound is
heard through bone as long as or lon-

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

(AC > BC).

The Nose and Paranasal Sinuses

Anatomy and Physiology. Review
the terms that describe the external
anatomy of the nose (Fig. 7-47).

Approximately the upper third of the
nose is supported by bone, the lower two
thirds by cartilage. Air enters the nasal
cavity through the anterior naris on either
side, then passes into the widened area
known as the vestibule and on through
the narrow nasal passage to the naso-
pharynx.

Ala nasi

Vestibule

Anterior
naris

Tip

Bridge

Dorsum

F I G U R E 7 – 4 7 . External anatomy of the nose.

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The medial wall of each nasal cavity is formed by
the nasal septum, which, like the external nose, is
supported by both bone and cartilage (Fig. 7-48).
It is covered by a mucous membrane well supplied
with blood. The vestibule, unlike the rest of the
nasal cavity, is lined with hair-bearing skin, not
mucosa.

Laterally, the anatomy is more complex (Fig. 7-49).
Curving bony structures, the turbinates, covered by a
highly vascular mucous membrane, protrude into the
nasal cavity. Below each turbinate is a groove, or
meatus, each named according to the turbinate above
it. The nasolacrimal duct drains into the inferior
meatus; most of the paranasal sinuses drain into the
middle meatus. Their openings are not usually visible.

The additional surface area provided by the turbinates
and their overlying mucosa aids the nasal cavities in
their principal functions: cleansing, humidification,
and temperature control of inspired air.

The paranasal sinuses are air-filled cavities within the bones of the skull. Like the
nasal cavities into which they drain, they are lined with mucous membrane.
Their locations are diagrammed in Figure 7-50. Only the frontal and maxillary
sinuses are readily accessible to clinical examination (Fig. 7-51).

Cranial cavity

Sphenoid sinus

Bony portion
of nasal septum

Soft palate
Hard palate

Cartilaginous portion
of nasal septum

Frontal sinus

F I G U R E 7 – 4 8 . Medial wall—left nasal cavity (mucosa removed).

Cranial cavity

Opening to
eustachian
tube

Hard palate

Vestibule

Inferior turbinate

Middle turbinate

Superior turbinate

Frontal sinus

Nasopharynx

Soft
palate

F I G U R E 7 – 4 9 . Lateral wall—nasal cavity.

Frontal
sinus

Orbit

Middle
turbinate
Maxillary
sinus

Inferior
turbinate

Inferior
meatus

Middle
meatus

Ethmoid
sinus

F I G U R E 7 – 5 0 . Cross-section of nasal cavity—anterior view.

Frontal
sinus

Maxillary
sinus

F I G U R E 7 – 5 1 . Frontal and maxillary sinuses.

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Techniques of Examination. Inspect the anterior and inferior surfaces of
the nose. Gentle pressure on the tip of the nose with your thumb usually widens
the nostrils. Use a penlight or otoscope light to obtain a partial view of each nasal
vestibule. If the nasal tip is tender, be gentle and manipulate the nose as little as
possible.

Note any asymmetry or deformity of the nose.

Test for nasal obstruction, if indicated, by pressing on each ala nasi in turn and
asking the patient to breathe in.

Inspect the inside of the nares with an otoscope and the largest available ear speculum.*
Tilt the patient’s head back a bit and insert the speculum gently into the vestibule of
each nostril, avoiding contact with the sensitive nasal septum (Fig. 7-53). Hold the
otoscope handle to one side to avoid the patient’s chin and improve your mobility.
By directing the speculum posteriorly, then upward in small steps, try to see the
inferior and middle turbinates, the nasal septum, and the narrow nasal passage
between them, as shown in Figure 7-54. Some asymmetry of the two sides is normal.

Tenderness of the nasal tip or alae

suggests local infection such as a

furuncle, particularly if there is a small

erythematous and swollen area.

Deviation of the lower septum is com-

mon and may be easily visible, as in

Figure 7-52. Deviation seldom

obstructs air flow.

Vestibule

F I G U R E 7 – 5 2 . Deviation of the

lower septum.

F I G U R E 7 – 5 3 . Inspect

inside the nares.

Nasal
passage

Septum

Inferior
turbinate

Middle
turbinate

F I G U R E 7 – 5 4 . Inferior and middle

turbinates.

Inspect the nasal mucosa, the nasal septum, and any abnormalities. Inspect:

â–  The nasal mucosa that covers the septum and turbinates. Note its color and
any swelling, bleeding, or exudate. If exudate is present, note its character:
clear, mucopurulent, or purulent. The nasal mucosa is normally somewhat
redder than the oral mucosa.

â–  The nasal septum. Note any deviation, inflammation, or perforation of the
septum. The lower anterior portion of the septum (where the patient’s finger
can reach) is a common source of epistaxis (nosebleed).

*A nasal illuminator, equipped with a short wide nasal speculum but lacking an otoscope’s mag-
nification, may also be used, but structures look much smaller. Otolaryngologists use special
equipment not widely available in general practice.

In viral rhinitis, the mucosa is red-
dened and swollen; in allergic rhinitis,
it may be pale, bluish, or red.

Fresh blood or crusting may be seen.

Causes of septal perforation include

trauma, surgery, and intranasal use of

cocaine or amphetamines, which also

cause septal ulceration.

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â–  Any abnormalities such as ulcers or polyps.

Inspection of the nasal cavity through the anterior naris is usually limited to the
vestibule, the anterior portion of the septum, and the lower and middle turbi-
nates. Examination of posterior abnormalities requires a nasopharyngeal mirror
and technique is beyond the scope of this book.

Place all nasal and ear specula outside your instrument case after use; then
discard or clean and disinfect them appropriately. Check the policies of your
institution.

Palpate for sinus tenderness. Press up on the frontal sinuses from under the bony
brows, avoiding pressure on the eyes (Fig. 7-56). Then press up on the maxillary
sinuses (Fig. 7-57).

Nasal polyps (Fig. 7-55) are pale

saclike growths of inflamed tissue

that can obstruct the air passage or

sinuses, seen in allergic rhinitis, aspirin
sensitivity, asthma, chronic sinus

infections, and cystic fibrosis.36

F I G U R E 7 – 5 5 . Nasal polyps.

Malignant tumors of the nasal cavity
occur rarely, associated with exposure

to tobacco or chronically inhaled

toxins.

F I G U R E 7 – 5 6 . Palpate the frontal

sinuses.

F I G U R E 7 – 5 7 . Palpate the

maxillary sinuses.

Local tenderness, together with

symptoms such as facial pain, pres-

sure or fullness, purulent nasal dis-

charge, nasal obstructions, and smell

disorder, especially when present for

>7 days, suggest acute bacterial
rhonosinusitis involving the frontal or
maxillary sinuses.34–36,71

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Mouth and Pharynx

Anatomy and Physiology. The
lips are muscular folds that surround the
entrance to the mouth. When opened,
the gums (gingiva) and teeth are visible
(Fig. 7-58). Note the scalloped shape of
the gingival margins and the pointed
interdental papillae.

The gingiva is firmly attached to the teeth
and to the maxilla and mandible in which
they are seated. In lighter-skinned peo-
ple, the gingiva is pale or coral pink and
lightly stippled. In darker-skinned peo-
ple, it may be diffusely or partly brown, as
shown below. A midline mucosal fold,
called a labial frenulum, connects each lip
with the gingiva. A shallow gingival sulcus
between the gum’s thin margin and each
tooth is not readily visible (but is probed and measured by dentists). Adjacent to
the gingiva is the alveolar mucosa, which merges with the labial mucosa of the lip
(Fig. 7-59).

Gingival margin Upper lip
(everted)

Interdental
papillae

F I G U R E 7 – 5 8 . Gingiva and interdental

papillae.

Gingiva

Alveolar
mucosa

Labial
mucosa

Labial
frenulum

F I G U R E 7 – 5 9 . Alveolar and labial mucosa, labial frenulum.

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The dorsum of the tongue is covered
with papillae, giving it a rough sur-
face. Some of these papillae look like
red dots, which contrast with the
thin white coat that often covers the
tongue. This patient has an erythem-
atous posterior pharynx (Fig. 7-62).

Each tooth, composed chiefly of dentin, lies rooted in a bony socket with only
its enamel-covered crown exposed. Small blood vessels and nerves enter the
tooth through its apex and pass into the pulp canal and pulp chamber
(Fig. 7-60).

Note that there are 32 adult teeth, conventionally numbered 1 to 16 right to left
on the upper jaw and 17 to 32 left to right on the lower jaw (Fig. 7-61).

Crown

Gingival
margin

Gingiva

Pulp
chamber

Bone

Root

Pulp
canal

Apex

Enamel

Gingival
sulcus

Dentin

F I G U R E 7 – 6 0 . Anatomy of a tooth.

Medial (central)
incisor

Lateral
incisor

Canine
(cuspid)

2nd premolar
(bicuspid)

1st molar
(6-year
molar)

2nd molar
(12-year
molar)

3rd molar
(wisdom
tooth)

1st premolar
(bicuspid)

F I G U R E 7 – 6 1 . Adult teeth.

Papillae

F I G U R E 7 – 6 2 . Dorsal papillae of the tongue.

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The undersurface of the tongue has no papillae.
Note the midline lingual frenulum that connects
the tongue to the floor of the mouth and the
ducts of the submandibular gland (Wharton
ducts) which pass forward and medially
(Fig. 7-63). They open on papillae that lie on
each side of the lingual frenulum. The paired
sublingual salivary glands lie just under the
floor of the mouth mucosa.

Above and behind the tongue rises an arch
formed by the anterior and posterior pillars, the
soft palate, and the uvula (Fig. 7-64). A mesh-
work of small blood vessels may web the soft
palate. The posterior pharynx is visible in the
recess behind the soft palate and tongue.

In Figure 7-64, note the right tonsil protruding
from the hollowed tonsillar fossa, or cavity,
between the anterior and posterior pillars. In
adults, tonsils are often small or absent, as in
the empty left tonsillar fossa.

The buccal mucosa lines the cheeks. Each parotid
duct, sometimes termed Stensen duct, opens
onto the buccal mucosa near the upper second
molar. Its location is frequently marked by its
own small papilla (Fig. 7-65).

Lingual
frenulum

Vein

Duct of
submandibular
gland

F I G U R E 7 – 6 3 . Undersurface of the tongue.

Posterior
pillar

Anterior
pillar

Right
tonsil

Hard palate

Soft palate

Uvula

Posterior
pharynx

Tongue

F I G U R E 7 – 6 4 . Anatomy of the posterior pharynx.

Buccal
mucosa

Opening of
the parotid
duct

Papilla

Upper lip
(retracted)

F I G U R E 7 – 6 5 . Buccal mucosa and parotid duct.

C H A P T E R 7 |

The Head and Neck 255

ANATOMY AND PHYSIOLOGY

Techniques of Examination. If the patient wears dentures, offer a paper
towel and ask the patient to remove them so that you can inspect the underlying
mucosa. If you detect any suspicious ulcers or nodules, put on a glove and
palpate any lesions, noting any thickening or infiltration of the tissues that might
suggest malignancy.

Inspect the following:

The Lips. Observe their color and moisture, and note any lumps, ulcers,
cracking, or scaliness.

The Oral Mucosa. Look into the
patient’s mouth and, with a good light
and the help of a tongue blade (Fig. 7-66),
inspect the oral mucosa for color, ulcers
(Fig. 7-67), white patches, and nodules.

In this patient (Fig. 7-66), the wavy white
line on the adjacent buccal mucosa devel-
oped where the upper and lower teeth
meet, related to irritation from sucking or
chewing.

The Gums and Teeth. Note the color of the gums, which are normally
pink. Brown patches may be present, especially but not exclusively in dark-
skinned individuals.

Inspect the gum margins and the interdental papillae for swelling or ulceration.

Inspect the teeth. Are any of them missing, discolored, misshapen, or abnormally
positioned? To assess tooth, jaw, or facial pain, palpate the teeth for looseness
and the gums with your gloved thumb and index finger.

The Roof of the Mouth. Inspect the color and architecture of the hard
palate.

Bright red edematous mucosa under-

neath a denture suggests denture sto-
matitis (denture sore mouth). There
may be ulcers or papillary granulation

tissue.

Watch for central cyanosis or pallor

from anemia. See Table 7-22, Abnor-

malities of the Lips, pp. 290–291.

F I G U R E 7 – 6 6 . Inspect the oral

mucosa.

F I G U R E 7 – 6 7 . Aphthous ulcer

on the labial mucosa.

See Table 7-23, Findings in the Phar-

ynx, Palate, and Oral Mucosa, pp. 292–

294.

Redness of the gingiva suggests gingi-
vitis, a black line might indicate lead
poisoning.

The interdental papillae are swollen in

gingivitis. See Table 7-24, Findings in
the Gums and Teeth, pp. 295–296.

Torus palatinus is a startling but
benign midline lump (see p. 293).

E X A M P L E S O F A B N O R M A L I T I E S

256 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

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The Tongue and the F