Generalities Conventional teaching has long recognized the abdomen as “the grave of the internist,” since in contrast to the chest, this cavity has been quite unyielding to physical exam. Although maneuvers devised by generations of physicians to unlock the secrets of its many organs have been for the most part wanting, there are still a few golden nuggets worth learning about. This chapter reviews sequentially the…
Generalities Lung auscultation has long suffered from a complex and onomatopoeic terminology that goes back to the original stethoscope and its inventor. Recent application of computer technology has rekindled this art by facilitating acoustic analysis. Still, its major difficulty lies not in the identification of sounds (which is much easier than for cardiac sounds and murmurs), but in their interpretation. And despite recent attempts at standardization,…
Generalities Chest inspection, palpation, and percussion are the foundations of physical exam. Percussion is 15 years older than the United States, the brainchild of an Austrian innkeeper’s son who figured out that patients’ chests could behave like barrels of wine. Although rather “ancient,” these maneuvers retain considerable value. Their skilled use may in fact still provide key pieces to our diagnostic mosaic. Indeed, bedside diagnosis of…
Generalities Cardiovascular examination is centered around five main components – all essential for making a diagnosis. In this section we shall discuss inspection , palpation , and percussion . Next we shall address auscultation, first with heart sounds and extra heart sounds, followed by murmurs. The chapter concludes with a discussion on cardiac POCUS and its role in augmenting the five traditional components of the cardiovascular…
Generalities The clinical breast examination (CBE) as screening tool for breast cancer is a controversial, changing field; it has mostly been studied in conjunction with screening mammography. (1) Inspection 1. Which areas should be examined? Breast tissue is contained in an imaginary pentagon, whose lateral border follows the midaxillary line, from the middle of the axilla down to the inframammary (or bra) line (fifth to sixth…
Generalities The thyroid may not be the most important organ in a busy general practice, but in physical diagnosis it is second only to the heart in number of examination errors and lack of physician’s confidence. This is unfortunate, as better skills may guide a more intelligent use of costly scans and better assessment of the likelihood of hyperthyroidism in anxious young patients. A Anatomic Review…
A Neck Features and Swellings (1) Generalities The neck is an important crossroad of anatomic structures and organ systems, the most important of which is the thyroid (discussed in Chapter 8 ). 1. What neck features should be identified during inspection? The most important is the contour . Abnormalities include: A buffalo hump at the base of the neck. A short neck , which is suggestive…
A The Nose (1) Generalities If you can excuse the pun, it is wise to be nosy about the nose. In fact, examination of this important facial appendix may reveal unsuspected abnormalities that lead to a diagnosis of either systemic diseases or capital sins (such as cocaine abuse). (2) The External Nose 1. What are the normal structures of the external nose? They are shown in…
Generalities The ear is an important site for physical examination; abnormalities may reflect either local or systemic disease. It also is an important sensory organ, whose function can be assessed (albeit in a rudimentary manner) with basic bedside tools. 1. What are the components of the ear? External ear (comprising the auricle and the external auditory canal) Middle ear Inner ear Nervous supply A External Ear…
Generalities The eye is often bypassed or cursorily examined. Yet from measurement of visual acuity to funduscopy, all components of the exam can unlock important secrets, not only of the eye but also of the body. Some findings are so important that they should be recognized by all practicing physicians. 1. Who should have visual acuity testing? Anyone. Measuring vision is like taking the vital signs…
A Basic Terminology and Diagnostic Techniques 1. How many skin diseases exist? What are the two main categories of skin lesions ? There are more than 1400 skin diseases. Yet, only 30 are important, common, and worth knowing. The first step toward their recognition is the separation of primary from secondary lesions ( Table 3.1 ). Primary lesions result only from disease and have not been…
Generalities Measuring vital signs is the initial but still essential part of bedside examination. Unfortunately, this task is often relegated to nonphysicians, sometimes even technicians. Yet, as the word implies, vital signs can provide a wealth of crucial information, some requiring special skills and knowledge. A Vital Statistics 1. What are the vital statistics? They are weight and height , both important measurements (see Chapter 1…
General Appearance 1. What is the value of carefully examining the patient’s general appearance? It is the Sherlockian value of making a diagnosis at first sight, sometimes while walking down a street. Attentive and knowledgeable observation is a time-honored skill of poets, physicians, and serial killers, beautifully articulated by Sir Arthur Conan Doyle (himself a doctor and a former student of the charismatic bedside diagnostician, Prof.…
General principles Clinical assessments are integral to undergraduate and postgraduate medical education and training, and are designed to verify that those involved in the care of patients meet safe clinical standards. Assessments can be formative and/or summative. Formative assessments (such as workplace-based assessments and progress tests) allow you to receive feedback on and monitor your own performance. Assessments such as these can be highly effective adjuncts to…
The previous chapters have covered the idealised process of taking a history and examining each system in depth. This chapter considers how this ‘toolbox’ of skills can be used selectively and adaptively to address the patient’s needs in specific circumstances. Adapting to different presentations Presentation in emergency Patients presenting with collapse or multiple injury may clearly be unable to engage in the normal systematic process of…
History taking, examination and investigation are the methods by which clinicians gather information to allow them to understand patients’ problems. Clinical reasoning is the analytical process by which this information is translated into diagnoses, therapeutic possibilities and prognoses. This chapter addresses how the clinical skills described in this book enable clinicians to reach diagnoses and other clinical decisions and communicate these to patients and colleagues in…
Around 1% of the population in high-income countries die each year. Although some deaths are unexpected, the majority are the result of one or more advanced, progressive conditions and occur in hospital, at the patient’s home or care home, or in a hospice. It is important to identify whether an acute deterioration or a new complication from an underlying health problem is reversible. This change may…
A deteriorating patient is one who becomes acutely unwell in the hospital setting. This can occur at any stage of a patient's illness but is more common if the patient has been admitted as an emergency case, has undergone surgery or has spent time in a high-dependency or intensive care setting. Common causes for deterioration include urinary and chest sepsis, bleeding, myocardial infarction, hypoglycaemia and pulmonary…
The frail patient A frail person typically suffers from multimorbidity (multiple illnesses) and has associated polypharmacy (multiple medications). They often have cognitive impairment, visual and hearing loss, low bodyweight, poor mobility due to muscular weakness, unstable balance and poor exercise tolerance. Their general functional reserve and the capacity of individual organs and physiological systems are impaired, making the individual potentially vulnerable to the effects of minor…
Mental disorders are very common, frequently coexist with physical disorders and cause much mortality and morbidity. Psychiatric assessment is, therefore, a required skill for all clinicians. It consists of four elements: history, mental state examination (MSE), selective physical examination and collateral information. Each element can be expanded considerably, so the assessment must be adapted to its purpose. Is it a quick screening of a patient presenting…