Lynn S. Bickley, MD, FACP Clinical Professor of Internal Medicine School of Medicine University of New Mexico Albuquerque, New Mexico

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 Chief, Division of General Pediatrics University of Rochester School of Medicine and Dentistry Rochester, New York

 

 

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7th Edition

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Library of Congress Cataloging-in-Publication Data

Bickley, Lynn S. Bates’ pocket guide to physical examination and history taking / Lynn S. Bickley, Peter G. Szilagyi. — 7th ed. p. ; cm. Pocket guide to physical examination and history taking Abridgement of: Bates’ guide to physical examination and history-taking. 11th ed. / Lynn S. Bickley, Peter G. Szilagyi. c2013.

Includes bibliographical references and index. Summary: “This concise pocket-sized guide presents the classic Bates approach to physical exami- nation and history taking in a quick-reference outline format. It contains all the critical information needed to obtain a clinically meaningful health history and to conduct a thorough physical assessment. Fully revised and updated, the Seventh Edition will help health professionals elicit relevant facts from the patient’s history, review examination procedures, highlight common findings, learn special assess- ment techniques, and sharpen interpretive skills.The book features a vibrant full-color art program and an easy-to-follow two-column format with step-by-step examination techniques on the left and abnormalities with differential diagnoses on the right.”—Provided by publisher.

ISBN 978-1-4511-7322-2 (pbk. : alk. paper) I. Bates, Barbara, 1928-2002. II. Szilagyi, Peter G. III. Bickley, Lynn S. Bates’ guide to physical examination and history-taking. IV. Title. V. Title: Pocket guide to physical examination and history taking.

[DNLM: 1. Physical Examination—methods—Handbooks. 2. Medical History Taking— methods—Handbooks. WB 39] 616.07′51—dc23 2012030529

Care has been taken to confirm the accuracy of the information presented and to describe gener- ally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be con- sidered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warn- ings and precautions. This is particularly important when the recommended agent is a new or infre- quently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsi- bility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice.

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To Randolph B. Schiffer, for lifelong care and support, and to students world-wide committed to clinical excellence.

 

 

 

I n t r o d u c t i o n

The Pocket Guide to Physical Examination and History Taking, 7th edition is a concise, portable text that: ● Describes how to interview the patient and take the health history. ● Provides an illustrated review of the physical examination. ● Reminds students of common, normal, and abnormal physical

findings. ● Describes special techniques of assessment that students may need in

specific instances. ● Provides succinct aids to interpretation of selected findings.

There are several ways to use the Pocket Guide: ● To review and remember the content of a health history. ● To review and rehearse the techniques of examination. This can be

done while learning a single section and again while combining the approaches to several body systems or regions into an integrated examination (see Chap. 1).

● To review common variations of normal and selected abnormalities. Observations are keener and more precise when the examiner knows what to look, listen, and feel for.

● To look up special techniques as the need arises. Maneuvers such as The Timed Get Up and Go test are included in the Special Techniques sections in each chapter.

● To look up additional information about possible findings, including abnormalities and standards of normal.

The Pocket Guide is not intended to serve as a primary text for learn- ing the skills of history taking or physical examination. Its detail is too brief for these purposes. It is intended instead as an aid for student review and recall and as a convenient, brief, and portable reference.

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C o n t e n t s

1 Overview: Physical Examination and History Taking 1

2 Clinical Reasoning, Assessment, and Recording Your Findings 15

3 Interviewing and the Health History 31 4 Beginning the Physical Examination: General

Survey, Vital Signs, and Pain 49

5 Behavior and Mental Status 67 6 The Skin, Hair, and Nails 83 7 The Head and Neck 99 8 The Thorax and Lungs 127 9 The Cardiovascular System 147 10 The Breasts and Axillae 167 11 The Abdomen 179 12 The Peripheral Vascular System 199 13 Male Genitalia and Hernias 211 14 Female Genitalia 225 15 The Anus, Rectum, and Prostate 241 16 The Musculoskeletal System 251 17 The Nervous System 285 18 Assessing Children: Infancy Through

Adolescence 323

19 The Pregnant Woman 359 20 The Older Adult 373

Index 395

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1

C H A P T E R

1Overview: Physical Examination and

History Taking

This chapter provides a road map to clinical proficiency in two critical areas: the health history and the physical examination.

For adults, the comprehensive history includes Identifying Data and Source of the History, Chief Complaint(s), Present Illness, Past History, Family History, Personal and Social History, and Review of Systems. New patients in the office or hospital merit a comprehensive health history; however, in many situations, a more flexible focused, or problem-oriented, interview is appropriate. The components of the comprehensive health history structure the patient’s story and the format of your written record, but the order shown below should not dictate the sequence of the interview. The interview is more fluid and should follow the patient’s leads and cues, as described in Chapter 3.

Over view: 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

medical record

◗ If appropriate, establish 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

(continued)

 

 

2 Bates’ Pocket Guide to Physical Examination and History Taking

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

Over view: Components of the Adult Health History (continued)

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. 3)

◗ May include medications, allergies, habits of smoking and alcohol, which frequently are pertinent to the present illness

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

categories: medical, surgical, obstetric/gynecologic,

and psychiatric

◗ Includes health maintenance practices such as

immunizations, 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, coronary artery

disease, etc.

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 symp- toms related to each major body system

Subjective Data Objective Data

What the patient tells you What you detect during the examination

The history, from Chief Complaint

through Review of Systems

All physical examination findings

The Comprehensive Adult Health History

As you elicit the adult health history, be sure to include the following: date and time of history; identifying data, which include age, gender, marital status, and occupation; and reliability, which reflects the quality of information the patient provides.

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Chapter 1 | Overview: Physical Examination and History Taking 3

CHIEF COMPLAINT(S)

Quote the patient’s own words. “My stomach hurts and I feel awful”; or “I have come for my regular check-up.”

PRESENT ILLNESS

This section is a complete, clear, and chronologic account of the prob- lems prompting the patient to seek care. It should include the prob- lem’s onset, the setting in which it has developed, its manifestations, and any treatments.

Every principal symptom should be well characterized, with descrip- tions of the seven features listed below and pertinent positives and negatives from relevant areas of the Review of Systems that help clarify the differential diagnosis.

The Seven Attributes of Every Symptom

◗ Location

◗ Quality

◗ Quantity or severity

◗ Timing, including onset, duration, and frequency

◗ Setting in which it occurs

◗ Aggravating and relieving factors

◗ Associated manifestations

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

HISTORY

List childhood illnesses, then list adult illnesses in each of four areas:

● Medical (e.g., diabetes, hypertension, hepatitis, asthma, HIV), with dates of onset; also information about hospitalizations with dates; number and gender of sexual partners; risky sexual practices

● Surgical (dates, indications, and types of operations)

 

 

4 Bates’ Pocket Guide to Physical Examination and History Taking

● Obstetric/gynecologic (obstetric history, menstrual history, birth control, and sexual function)

● Psychiatric (illness and time frame, diagnoses, hospitalizations, and treatments)

Also discuss Health Maintenance, including immunizations, such as tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, influenza, varicella, hepatitis B, Haemophilus influenzae type b, pneumococcal vaccine, and herpes zoster vaccine; and screening tests, such as tuber- culin tests, Pap smears, mammograms, stool tests, for occult blood colonoscopy, and cholesterol tests, together with the results and the dates they were last performed.