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The History and Interviewing Process |
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1 | (37) |
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2 | (1) |
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Partnership with the Patient |
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|
2 | (1) |
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An Ethical Context to the Partnership with the Patient |
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|
2 | (1) |
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|
3 | (1) |
|
Allopathic, Complementary, and Alternative Care |
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|
3 | (1) |
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Communicating with the Patient |
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|
4 | (9) |
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Factors That Enhance Communication |
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|
4 | (1) |
|
The Basic Requirements of Healthy Communication |
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|
5 | (3) |
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|
8 | (5) |
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|
13 | (24) |
|
Setting for the Interview |
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14 | (1) |
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|
14 | (1) |
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|
15 | (2) |
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An Approach to Sensitive Issues |
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|
17 | (5) |
|
Outline of Clinical History |
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|
22 | (15) |
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37 | (1) |
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|
38 | (13) |
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38 | (1) |
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39 | (1) |
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Distinguishing Physical Characteristics |
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|
39 | (1) |
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39 | (2) |
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The Blurring of Cultural Distinctions |
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41 | (1) |
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The Primacy of the Individual in Health Care |
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41 | (1) |
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Professional Cultures Within the Health Professions |
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42 | (2) |
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The Impact of Culture on Illness |
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|
44 | (1) |
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The Components of a Cultural Response |
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|
45 | (5) |
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|
45 | (2) |
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Health Beliefs and Practices |
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|
47 | (1) |
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48 | (1) |
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Diet and Nutritional Practices |
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|
48 | (2) |
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|
50 | (1) |
|
Examination Techniques and Equipment |
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|
51 | (35) |
|
Precautions to Prevent Infection |
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|
51 | (2) |
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53 | (2) |
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55 | (4) |
|
Patient Positions and Draping |
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|
55 | (1) |
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55 | (1) |
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56 | (1) |
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57 | (2) |
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59 | (1) |
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Measurement of Vital Signs |
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|
59 | (3) |
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|
59 | (1) |
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59 | (1) |
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60 | (1) |
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61 | (1) |
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62 | (1) |
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Measurement of Height and Weight |
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|
62 | (2) |
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Modifications for Patients with Disabilities |
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|
64 | (3) |
|
Patients with Mobility Impairments |
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|
65 | (1) |
|
Patients with Sensory Impairment |
|
|
66 | (1) |
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Special Concerns for Patients with Disabilities |
|
|
66 | (1) |
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|
67 | (19) |
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|
67 | (2) |
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|
69 | (1) |
|
Fetal Monitoring Equipment |
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|
70 | (1) |
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|
70 | (2) |
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|
72 | (1) |
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|
72 | (4) |
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|
76 | (1) |
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|
76 | (1) |
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|
76 | (1) |
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|
77 | (1) |
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|
78 | (1) |
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|
79 | (1) |
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Percussion (Reflex) Hammer |
|
|
79 | (1) |
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|
80 | (1) |
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|
80 | (1) |
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|
81 | (1) |
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|
81 | (1) |
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|
82 | (1) |
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|
82 | (1) |
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|
83 | (1) |
|
Calipers for Skinfold Thickness |
|
|
84 | (1) |
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|
84 | (2) |
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|
|
86 | (20) |
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|
86 | (2) |
|
Review of Related History |
|
|
88 | (1) |
|
History of Present Illness |
|
|
88 | (1) |
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|
|
88 | (1) |
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|
|
88 | (1) |
|
Personal and Social History |
|
|
89 | (1) |
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|
|
89 | (13) |
|
Physical Appearance and Behavior |
|
|
90 | (1) |
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|
90 | (5) |
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|
|
95 | (1) |
|
Speech and Language Skills |
|
|
96 | (1) |
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|
|
97 | (5) |
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|
|
102 | (4) |
|
Disorders of Altered Mental Status |
|
|
102 | (2) |
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|
|
104 | (1) |
|
|
|
104 | (2) |
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|
106 | (32) |
|
|
|
106 | (6) |
|
Differences in Growth by Organ System |
|
|
107 | (5) |
|
Review of Related History |
|
|
112 | (2) |
|
History of Present Illness |
|
|
112 | (1) |
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|
|
113 | (1) |
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|
|
113 | (1) |
|
Personal and Social History |
|
|
113 | (1) |
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|
|
114 | (18) |
|
|
|
114 | (1) |
|
Weight and Standing Height |
|
|
114 | (1) |
|
Waist-to-Hip Circumference Ratio |
|
|
115 | (1) |
|
Triceps Skinfold Thickness |
|
|
115 | (2) |
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|
|
117 | (1) |
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|
|
118 | (1) |
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|
|
118 | (1) |
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|
|
119 | (2) |
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|
|
121 | (1) |
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|
|
121 | (3) |
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|
|
124 | (1) |
|
Upper-to-Lower Segment Ratio |
|
|
125 | (1) |
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|
|
125 | (7) |
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|
|
132 | (6) |
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|
|
132 | (1) |
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|
|
133 | (5) |
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|
|
138 | (23) |
|
|
|
138 | (4) |
|
|
|
138 | (2) |
|
|
|
140 | (1) |
|
|
|
140 | (1) |
|
|
|
140 | (2) |
|
Review of Related History |
|
|
142 | (3) |
|
History of Present Illness |
|
|
142 | (1) |
|
|
|
142 | (1) |
|
|
|
143 | (1) |
|
Personal and Social History |
|
|
143 | (2) |
|
|
|
145 | (11) |
|
|
|
145 | (1) |
|
|
|
145 | (2) |
|
Determination of Diet Adequacy |
|
|
147 | (1) |
|
Measures of Nutrient Analysis |
|
|
147 | (1) |
|
Measures of Nutrient Adequacy |
|
|
148 | (6) |
|
|
|
154 | (1) |
|
|
|
155 | (1) |
|
|
|
156 | (5) |
|
|
|
161 | (8) |
|
|
|
162 | (1) |
|
Review of Related History |
|
|
162 | (1) |
|
|
|
162 | (1) |
|
Personal and Social History |
|
|
162 | (1) |
|
|
|
163 | (6) |
|
|
|
164 | (5) |
|
|
|
169 | (61) |
|
|
|
169 | (3) |
|
|
|
169 | (1) |
|
|
|
170 | (1) |
|
|
|
170 | (1) |
|
|
|
170 | (2) |
|
Review of Related History |
|
|
172 | (3) |
|
History of Present Illness |
|
|
173 | (1) |
|
|
|
173 | (1) |
|
|
|
174 | (1) |
|
Personal and Social History |
|
|
174 | (1) |
|
|
|
175 | (30) |
|
|
|
175 | (1) |
|
|
|
175 | (16) |
|
|
|
191 | (1) |
|
|
|
191 | (14) |
|
|
|
205 | (25) |
|
Skin: Nonmalignant Abnormalities |
|
|
205 | (8) |
|
Skin: Malignant Abnormalities |
|
|
213 | (3) |
|
|
|
216 | (1) |
|
|
|
217 | (1) |
|
|
|
218 | (2) |
|
Nails: Changes Associated with Systemic Disease |
|
|
220 | (1) |
|
Nails: Periungual Growths |
|
|
221 | (9) |
|
|
|
230 | (24) |
|
|
|
230 | (10) |
|
|
|
236 | (1) |
|
|
|
236 | (2) |
|
|
|
238 | (1) |
|
|
|
239 | (1) |
|
|
|
239 | (1) |
|
|
|
239 | (1) |
|
Review of Related History |
|
|
240 | (2) |
|
History of Present Illness |
|
|
240 | (1) |
|
|
|
241 | (1) |
|
|
|
242 | (1) |
|
|
|
242 | (8) |
|
|
|
242 | (1) |
|
|
|
242 | (2) |
|
|
|
244 | (3) |
|
|
|
247 | (1) |
|
|
|
247 | (3) |
|
|
|
250 | (4) |
|
|
|
254 | (26) |
|
|
|
254 | (5) |
|
Review of Related History |
|
|
259 | (3) |
|
History of Present Illness |
|
|
260 | (1) |
|
|
|
261 | (1) |
|
|
|
261 | (1) |
|
Personal and Social History |
|
|
261 | (1) |
|
|
|
262 | (9) |
|
|
|
262 | (1) |
|
|
|
262 | (2) |
|
|
|
264 | (7) |
|
|
|
271 | (9) |
|
|
|
271 | (4) |
|
|
|
275 | (2) |
|
|
|
277 | (3) |
|
|
|
280 | (36) |
|
|
|
280 | (5) |
|
|
|
280 | (1) |
|
|
|
281 | (4) |
|
Review of Related History |
|
|
285 | (2) |
|
History of Present Illness |
|
|
285 | (1) |
|
|
|
285 | (1) |
|
|
|
285 | (1) |
|
Personal and Social History |
|
|
286 | (1) |
|
|
|
287 | (18) |
|
|
|
287 | (1) |
|
|
|
287 | (1) |
|
|
|
288 | (5) |
|
|
|
293 | (1) |
|
Ophthalmoscopic Examination |
|
|
294 | (11) |
|
|
|
305 | (11) |
|
|
|
305 | (2) |
|
|
|
307 | (1) |
|
|
|
307 | (6) |
|
|
|
313 | (3) |
|
|
|
316 | (44) |
|
|
|
316 | (9) |
|
|
|
316 | (3) |
|
Nose, Nasopharynx, and Sinuses |
|
|
319 | (3) |
|
|
|
322 | (3) |
|
Review of Related History |
|
|
325 | (4) |
|
History of Present Illness |
|
|
325 | (3) |
|
|
|
328 | (1) |
|
|
|
328 | (1) |
|
Personal and Social History |
|
|
328 | (1) |
|
|
|
329 | (24) |
|
|
|
329 | (1) |
|
|
|
329 | (5) |
|
Nose, Nasopharynx, and Sinuses |
|
|
334 | (2) |
|
|
|
336 | (7) |
|
|
|
343 | (1) |
|
|
|
344 | (1) |
|
Nose and Sinuses (Infants) |
|
|
345 | (1) |
|
|
|
346 | (2) |
|
|
|
348 | (1) |
|
Nose and Sinuses (Children) |
|
|
348 | (1) |
|
|
|
349 | (1) |
|
Ears and Hearing (Older Adults) |
|
|
350 | (1) |
|
|
|
350 | (1) |
|
|
|
351 | (2) |
|
|
|
353 | (7) |
|
|
|
353 | (2) |
|
|
|
355 | (1) |
|
|
|
355 | (5) |
|
|
|
360 | (54) |
|
|
|
360 | (8) |
|
Chemical and Neurologic Control of Respiration |
|
|
364 | (2) |
|
|
|
366 | (2) |
|
Review of Related History |
|
|
368 | (2) |
|
History of Present Illness |
|
|
368 | (1) |
|
|
|
368 | (1) |
|
|
|
369 | (1) |
|
Personal and Social History |
|
|
369 | (1) |
|
|
|
370 | (29) |
|
|
|
370 | (1) |
|
|
|
371 | (6) |
|
|
|
377 | (3) |
|
|
|
380 | (3) |
|
|
|
383 | (8) |
|
Measures of Pulmonary Function |
|
|
391 | (1) |
|
|
|
392 | (7) |
|
|
|
399 | (15) |
|
|
|
414 | (45) |
|
|
|
414 | (10) |
|
|
|
414 | (3) |
|
|
|
417 | (3) |
|
|
|
420 | (4) |
|
Review of Related History |
|
|
424 | (4) |
|
History of Present Illness |
|
|
424 | (2) |
|
|
|
426 | (1) |
|
|
|
426 | (1) |
|
Personal and Social History |
|
|
427 | (1) |
|
|
|
428 | (18) |
|
|
|
428 | (1) |
|
|
|
429 | (1) |
|
|
|
430 | (2) |
|
|
|
432 | (1) |
|
|
|
432 | (14) |
|
|
|
446 | (13) |
|
|
|
446 | (6) |
|
Abnormalities in Heart Rate and Rhythm |
|
|
452 | (7) |
|
|
|
459 | (33) |
|
|
|
459 | (6) |
|
|
|
459 | (6) |
|
Review of Related History |
|
|
465 | (3) |
|
History of Present Illness |
|
|
465 | (1) |
|
|
|
466 | (1) |
|
|
|
466 | (1) |
|
Personal and Social History |
|
|
466 | (2) |
|
|
|
468 | (18) |
|
|
|
468 | (1) |
|
|
|
468 | (6) |
|
|
|
474 | (4) |
|
|
|
478 | (8) |
|
|
|
486 | (6) |
|
|
|
486 | (2) |
|
Jugular Venous Pressure Disorders |
|
|
488 | (4) |
|
|
|
492 | (29) |
|
|
|
492 | (3) |
|
Review of Related History |
|
|
495 | (6) |
|
History of Present Illness |
|
|
495 | (1) |
|
|
|
496 | (1) |
|
|
|
496 | (1) |
|
Personal and Social History |
|
|
497 | (4) |
|
|
|
501 | (14) |
|
|
|
501 | (1) |
|
|
|
501 | (4) |
|
|
|
505 | (10) |
|
|
|
515 | (6) |
|
|
|
521 | (58) |
|
|
|
521 | (7) |
|
|
|
521 | (3) |
|
|
|
524 | (1) |
|
|
|
524 | (1) |
|
|
|
524 | (1) |
|
|
|
525 | (1) |
|
Kidneys, Ureters, and Bladder |
|
|
525 | (1) |
|
Musculature and Connective Tissues |
|
|
525 | (1) |
|
|
|
525 | (3) |
|
Review of Related History |
|
|
528 | (4) |
|
History of Present Illness |
|
|
528 | (2) |
|
|
|
530 | (1) |
|
|
|
530 | (1) |
|
Personal and Social History |
|
|
531 | (1) |
|
|
|
532 | (35) |
|
|
|
532 | (1) |
|
|
|
532 | (1) |
|
|
|
533 | (3) |
|
|
|
536 | (1) |
|
|
|
537 | (3) |
|
|
|
540 | (9) |
|
|
|
549 | (8) |
|
|
|
557 | (1) |
|
Auscultation and Percussion |
|
|
558 | (1) |
|
|
|
559 | (2) |
|
|
|
561 | (1) |
|
|
|
562 | (1) |
|
|
|
562 | (1) |
|
|
|
563 | (4) |
|
|
|
567 | (12) |
|
|
|
567 | (5) |
|
|
|
572 | (2) |
|
|
|
574 | (1) |
|
|
|
574 | (1) |
|
|
|
574 | (5) |
|
|
|
579 | (62) |
|
|
|
579 | (9) |
|
|
|
579 | (2) |
|
|
|
581 | (2) |
|
|
|
583 | (5) |
|
Review of Related History |
|
|
588 | (6) |
|
History of Present Illness |
|
|
588 | (1) |
|
|
|
589 | (2) |
|
|
|
591 | (1) |
|
Personal and Social History |
|
|
591 | (3) |
|
|
|
594 | (30) |
|
|
|
594 | (1) |
|
|
|
594 | (1) |
|
|
|
595 | (1) |
|
|
|
595 | (1) |
|
|
|
596 | (2) |
|
|
|
598 | (6) |
|
|
|
604 | (4) |
|
|
|
608 | (16) |
|
|
|
624 | (17) |
|
Lesions From Sexually Transmitted Infections |
|
|
625 | (3) |
|
|
|
628 | (4) |
|
|
|
632 | (2) |
|
|
|
634 | (3) |
|
|
|
637 | (4) |
|
|
|
641 | (25) |
|
|
|
641 | (3) |
|
|
|
644 | (1) |
|
Review of Related History |
|
|
644 | (3) |
|
History of Present Illness |
|
|
645 | (1) |
|
|
|
646 | (1) |
|
|
|
646 | (1) |
|
Personal and Social History |
|
|
646 | (1) |
|
|
|
647 | (9) |
|
|
|
647 | (1) |
|
|
|
648 | (4) |
|
Inspection and Palpation (Infants) |
|
|
652 | (1) |
|
|
|
653 | (1) |
|
Inspection and Palpation (Children) |
|
|
653 | (3) |
|
|
|
656 | (10) |
|
|
|
657 | (4) |
|
|
|
661 | (5) |
|
Anus, Rectum, and Prostate |
|
|
666 | (22) |
|
|
|
666 | (3) |
|
Review of Related History |
|
|
669 | (2) |
|
History of Present Illness |
|
|
669 | (1) |
|
|
|
669 | (1) |
|
|
|
669 | (1) |
|
Personal and Social History |
|
|
670 | (1) |
|
|
|
671 | (1) |
|
|
|
671 | (10) |
|
|
|
671 | (1) |
|
|
|
671 | (1) |
|
Sacrococcygeal and Perianal Areas |
|
|
671 | (1) |
|
|
|
672 | (1) |
|
|
|
672 | (2) |
|
|
|
674 | (1) |
|
Lateral and Posterior Rectal Walls |
|
|
674 | (1) |
|
|
|
674 | (1) |
|
Anterior Rectal Wall and Prostate |
|
|
674 | (2) |
|
|
|
676 | (1) |
|
|
|
676 | (5) |
|
|
|
681 | (7) |
|
Anus, Rectum, and Surrounding Skin |
|
|
681 | (3) |
|
|
|
684 | (4) |
|
|
|
688 | (70) |
|
|
|
688 | (13) |
|
|
|
694 | (1) |
|
|
|
694 | (4) |
|
|
|
698 | (3) |
|
Review of Related History |
|
|
701 | (3) |
|
History of Present Illness |
|
|
701 | (1) |
|
|
|
702 | (1) |
|
|
|
702 | (1) |
|
Personal and Social History |
|
|
702 | (2) |
|
|
|
704 | (43) |
|
|
|
704 | (1) |
|
|
|
705 | (1) |
|
|
|
706 | (1) |
|
|
|
706 | (1) |
|
|
|
707 | (1) |
|
Specific Joints and Muscles |
|
|
707 | (19) |
|
|
|
726 | (21) |
|
|
|
747 | (11) |
|
|
|
751 | (7) |
|
|
|
758 | (51) |
|
|
|
758 | (13) |
|
|
|
761 | (4) |
|
Spinal Cord and Spinal Tracts |
|
|
765 | (6) |
|
Review of Related History |
|
|
771 | (3) |
|
History of Present Illness |
|
|
771 | (2) |
|
|
|
773 | (1) |
|
|
|
773 | (1) |
|
Personal and Social History |
|
|
773 | (1) |
|
|
|
774 | (27) |
|
|
|
774 | (1) |
|
|
|
775 | (5) |
|
Proprioception and Cerebellar Function |
|
|
780 | (5) |
|
|
|
785 | (4) |
|
|
|
789 | (2) |
|
|
|
791 | (10) |
|
|
|
801 | (8) |
|
Disorders of the Central Nervous System |
|
|
801 | (4) |
|
Disorders of the Peripheral Nervous System |
|
|
805 | (4) |
|
Sports Participation Evaluation |
|
|
809 | (13) |
|
|
|
822 | (30) |
|
|
|
822 | (2) |
|
|
|
824 | (2) |
|
|
|
824 | (2) |
|
The Professional as Observer |
|
|
826 | (1) |
|
|
|
826 | (2) |
|
|
|
828 | (1) |
|
|
|
828 | (1) |
|
|
|
829 | (1) |
|
|
|
829 | (1) |
|
Patient Seated, Wearing Gown |
|
|
829 | (2) |
|
Patient Seated, Back Exposed |
|
|
831 | (1) |
|
Patient Seated, Chest Exposed |
|
|
831 | (1) |
|
Patient Reclining 45 Degrees |
|
|
832 | (1) |
|
Patient Supine, Chest Exposed |
|
|
832 | (1) |
|
Patient Supine, Abdomen Exposed |
|
|
833 | (1) |
|
Patient Supine, Legs Exposed |
|
|
834 | (1) |
|
Patient Sitting, Lap Draped |
|
|
834 | (1) |
|
|
|
835 | (1) |
|
Female Patient, Lithotomy Position |
|
|
836 | (1) |
|
Male Patient, Bending Forward |
|
|
837 | (1) |
|
|
|
838 | (1) |
|
|
|
839 | (1) |
|
|
|
839 | (4) |
|
|
|
843 | (1) |
|
|
|
844 | (1) |
|
Child Relatively Supine, Still on Lap, Diaper Loosened |
|
|
845 | (1) |
|
|
|
845 | (1) |
|
Child Returns to Parent's Lap |
|
|
845 | (2) |
|
|
|
847 | (2) |
|
|
|
849 | (3) |
|
Taking the Next Steps: Critical Thinking |
|
|
852 | (7) |
|
|
|
852 | (1) |
|
|
|
852 | (7) |
|
Assessment, Judgment, and Evidence |
|
|
852 | (1) |
|
|
|
853 | (1) |
|
|
|
854 | (1) |
|
Possible Barriers to Critical Thinking |
|
|
855 | (2) |
|
Validity of the Clinical Examination |
|
|
857 | (1) |
|
|
|
857 | (1) |
|
The Management Plan/Setting Priorities |
|
|
857 | (2) |
|
|
|
859 | (29) |
|
|
|
860 | (3) |
|
|
|
861 | (1) |
|
|
|
861 | (2) |
|
Problem-Oriented Medical Record |
|
|
863 | (3) |
|
Comprehensive Health History and Physical Examination |
|
|
863 | (1) |
|
|
|
863 | (1) |
|
|
|
864 | (1) |
|
|
|
864 | (1) |
|
|
|
864 | (1) |
|
|
|
865 | (1) |
|
|
|
865 | (1) |
|
|
|
865 | (1) |
|
Problem-Oriented Medical Record Format |
|
|
866 | (10) |
|
|
|
866 | (2) |
|
|
|
868 | (1) |
|
Physical Examination Findings |
|
|
869 | (3) |
|
Assessment (for Each Problem on Problem List) |
|
|
872 | (1) |
|
Plan (for Each Problem on Problem List) |
|
|
872 | (4) |
|
|
|
876 | (11) |
|
|
|
876 | (8) |
|
|
|
884 | (3) |
|
Episodic Note Sample Write-Up |
|
|
887 | (1) |
|
|
|
887 | (1) |
|
Emergency or Life-Threatening Situations |
|
|
888 | (88) |
|
The ABCs of Primary Assessment |
|
|
888 | (10) |
|
|
|
890 | (4) |
|
|
|
894 | (4) |
|
|
|
898 | (4) |
|
|
|
898 | (1) |
|
|
|
898 | (1) |
|
|
|
898 | (4) |
|
Records and Legal Considerations |
|
|
902 | (3) |
|
|
|
902 | (1) |
|
|
|
903 | (1) |
|
Advance Directives, Living Wills, and Durable Power of Attorney for Health Care |
|
|
903 | (2) |
|
|
|
905 | (2) |
|
Photo and Illustration Credits |
|
|
907 | (2) |
|
|
|
909 | (10) |
|
|
|
919 | (9) |
|
|
|
|
Appendix A: Conversion Tables |
|
|
928 | (1) |
|
Appendix B: Temperature Equivalents |
|
|
929 | (1) |
|
Appendix C: Height/Weight Tables and Charts |
|
|
930 | (20) |
|
Appendix D: Denver II Developmental Screening Tool |
|
|
950 | (3) |
|
Appendix E: Dietary Reference Intakes |
|
|
953 | (4) |
|
Appendix F: Nutrition Screening Forms |
|
|
957 | (11) |
|
Appendix G: Anthropometric Measurements |
|
|
968 | (3) |
|
Appendix H: Abbreviations |
|
|
971 | (2) |
|
|
|
973 | (3) |
|
Appendix J: English-to-Spanish Translation Guide: Key Medical Questions |
|
|
976 | |