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…
Babies A baby is a neonate for its first 4 weeks and an infant for its first year. Neonates are classified by gestational age or birthweight ( Box 15.1 ). 15.1 Classification of newborn infants Birthweight Extremely low birthweight (ELBW): <1000 g Very low birthweight (VLBW): <1500 g Low birthweight (LBW): <2500 g Normal: ≥2500 g Gestational age Extremely preterm: <28 weeks Preterm: <37 weeks (<259th day) Term: 37–42 weeks Post-term: >42 weeks (>294th day) The history Ask…
Dermatological conditions are very common (10–15% of general practice consultations) and present to healthcare professionals in all specialties. In the UK, 50% are lesions (‘lumps and bumps’), including skin cancers, and most of the remainder are acute and chronic inflammatory disorders (‘rashes’), including infections, with genetic conditions accounting for a small minority; this ratio will vary across the world, although the principles of skin assessment are…
The history Common presenting symptoms Pain In musculoskeletal pain, the acronym SOCRATES (see Box 2.2 , p. 12) suggests questions that help reveal useful diagnostic clues. Site Fig. 13.1 illustrates the anatomy of a typical joint. Determine which component is painful: the joint (arthralgia), muscle (myalgia) or other soft tissue. Pain may be localised and may suggest the diagnosis, for example, a red, hot, tender first metatarsophalangeal joint…
Anatomy and physiology The kidneys lie posteriorly in the abdomen, retroperitoneally on either side of the spine at the T12–L3 level, and are 11–14 cm long ( Fig. 12.1 ). The right kidney lies 1.5 cm lower than the left because of the liver. The liver and spleen lie anterior to the kidneys. The kidneys move downwards during inspiration as the lungs expand. Together, the kidneys receive approximately 25%…
Breast Anatomy and physiology The adult breast lies over the pectoralis major and serratus anterior muscles; it extends from the lateral border of the sternum into the lower axilla as the tail of Spence. The centre of the breast is the nipple, which is composed mostly of smooth muscle fibres. The areola is the pigmented skin around the nipple that contains numerous Montgomery glands. The breast…
Endocrine glands synthesise hormones that are released into the circulation and act at distant sites. Diseases may result from excessive or inadequate hormone production, target organ hypersensitivity or resistance to the hormone. The main endocrine glands are the pituitary, thyroid, adrenals, gonads (testes and ovaries), parathyroids and the endocrine pancreas. With the notable exception of the pancreatic islet cells (which release insulin) and the parathyroids, most…