Advanced Assessment

by Goolsby, Mary Jo; Grubbs, Laurie

• ISBN13: 9780803613638
• ISBN10: 0803613636
• Format: Paperback
• Copyright: 2005-09-30
• Publisher: F a Davis Co

Summary

The only book directed specifically at assessing patients with a specific complaint-a perfect tool that can be applied in the classroom and as a working utility in clinical practice. Unique in its approach, this new book takes users beyond the identification of physical assessment abnormalities to arrive at a differential diagnosis of the patient's health problem. Readers learn how to incorporate physical examination, patient history, and diagnostic studies to accurately diagnosis a patient's problem.

Table of Contents

PART 1: The Art of Assessment and Clinical Decision Making	1	(10)
Chapter 1: Assessment and Clinical Decision-Making: An Overview	2	(9)
History	2	(1)
Physical Examination	3	(1)
Diagnostic Studies	4	(1)
Diagnostic Statistics	4	(2)
Clinical Decision-Making Resources	6	(1)
The Diagnostic Process	7	(2)
Summary	9	(1)
Suggested Readings	10	(1)
PART 2: Advanced Assessment and Differential Diagnosis by Body Regions and Systems	11	(410)
Chapter 2: Skin	12	(20)
History	12	(1)
General Integumentary History	12	(1)
Past Medical History	13	(1)
Family History	13	(1)
Habits	13	(1)
Physical Examination	13	(4)
Order of the Exam	13	(3)
Assessing Skin Lesions	16	(1)
Differential Diagnosis of Common Chief Complaints	17	(14)
Vesicles (Blisters)	17	(3)
Bullae (Large Blisters)	20	(1)
Pustules	20	(1)
Keratotic Lesions	21	(1)
Raised, Skin-Colored Lesions	22	(2)
White Lesions	24	(1)
Brown Lesions	25	(1)
Inflammatory or Red Lesions	26	(4)
Eczematous Lesions with Excoriations	30	(1)
Suggested Readings	31	(1)
Chapter 3: Head, Face, and Neck	32	(19)
History	32	(1)
General History	32	(1)
Past Medical History	33	(1)
Family History	33	(1)
Habits	33	(1)
Physical Examination	33	(1)
Differential Diagnosis of Chief Complaints	33	(16)
Head Pain and Headache	33	(2)
Jaw Pain and Facial Pain	35	(4)
Facial Swelling	39	(2)
Facial Numbness	41	(1)
Scalp and Face Pruritus	42	(1)
Neck Fullness/Mass or Pain	43	(4)
Difficulty Swallowing	47	(2)
Suggested Readings	49	(2)
Chapter 4: The Eye	51	(26)
History	51	(2)
General Eye History	51	(1)
Past Medical History	51	(1)
Family History	52	(1)
Habits	52	(1)
Physical Examination	53	(4)
Order of the Examination	53	(1)
Visual Acuity	53	(1)
Peripheral Vision	54	(1)
Alignment	54	(1)
Accessory Structures	54	(1)
External Eye Structures	54	(1)
Pupils	54	(1)
Anterior Chamber and Lens	54	(1)
Cranial Nerves	54	(2)
Funduscopic Examination	56	(1)
Differential Diagnosis of Chief Complaints	57	(18)
Visual Disturbances	57	(7)
Reddened Eye	64	(5)
Eye Pain	69	(2)
Eye Discharge	71	(1)
Ptosis	72	(2)
Double Vision	74	(1)
Suggested Readings	75	(2)
Chapter 5: Ear, Nose, Mouth, and Throat	77	(40)
History	77	(3)
General History	77	(1)
History of the Present Illness	77	(2)
Past Medical History	79	(1)
Family History	80	(1)
Habits	80	(1)
Review of Systems	80	(1)
Physical Examination	80	(4)
Order of the Examination	80	(4)
Differential Diagnosis of Chief Complaints: Ear	84	(12)
Ear Pain (Otalgia)	84	(4)
Ear Discharge (Otorrhea)	88	(2)
Decreased Hearing or Hearing Loss	90	(4)
Ringing (Tinnitus)	94	(1)
Ear Fullness	95	(1)
Differential Diagnosis of Chief Complaints: Nose	96	(6)
Bleeding (Epistaxis)	96	(4)
Congestion and/or Drainage	100	(2)
Loss of Smell	102	(1)
Differential Diagnosis of Chief Complaints: Mouth	102	(7)
Mouth Sores (Painful and Painless)	102	(6)
Mouth Pain Without Obvious Lesions	108	(1)
Differential Diagnosis of Chief Complaints: Throat	109	(7)
Sore Throat or Throat Pain	109	(5)
Hoarseness	114	(2)
Suggested Readings	116	(1)
Chapter 6: Cardiac and Peripheral Vascular Systems	117	(35)
Cardiac System	117	(1)
Anatomy and Physiology	117	(3)
Heart Sounds	117	(2)
The Cardiac Cycle	119	(1)
History	120	(1)
General History	120	(1)
Past Medical History	121	(1)
Family History	121	(1)
Habits	121	(1)
Physical Examination	121	(2)
General Assessment	121	(1)
Inspection	122	(1)
Auscultation	122	(1)
Palpation	123	(1)
Percussion	123	(1)
Cardiovascular Laboratory Tests	123	(1)
Differential Diagnosis of Chief Complaints	124	(21)
Palpitations or Arrhythmia	124	(2)
Irregular Pulse	126	(2)
Chest Pain	128	(4)
Patient History of Heart Murmur	132	(6)
Elevated Blood Pressure	138	(2)
History of Elevated Lipids	140	(2)
Difficulty Breathing and Shortness of Breath	142	(3)
Acute and Subacute Bacterial Endocarditis	145	(1)
Peripheral Vascular System	145	(1)
Differential Diagnosis of Chief Complaints	146	(4)
Peripheral Edema	146	(2)
Leg Pain	148	(2)
References	150	(2)
Chapter 7: Respiratory System	152	(16)
History	152	(2)
Symptom Analysis	152	(1)
Past Medical and Family History	153	(1)
Habits	153	(1)
Physical Examination	154	(3)
Inspection	154	(1)
Palpation	154	(1)
Percussion	155	(1)
Auscultation	155	(1)
Diagnostic Studies	156	(1)
Imaging Studies	157	(1)
Differential Diagnosis of Chief Complaints	157	(10)
Cough	157	(5)
Shortness of Breath and Dyspnea	162	(2)
Wheezing and Chest Tightness	164	(1)
Hentoptysis	165	(1)
Pleuritic Pain	165	(2)
References	167	(1)
Suggested Readings	167	(1)
Chapter 8: Breasts	168	(15)
History	168	(1)
General History: Symptoms Analysis and Review of Systems	169	(1)
Past Medical History	169	(1)
Family History	169	(1)
Habits	169	(1)
Physical Examination	169	(3)
Order of the Examination	170	(1)
Special Considerations	171	(1)
Differential Diagnosis of Chief Complaints	172	(10)
Breast Mass	172	(3)
Breast Pain	175	(3)
Breast Discharge	178	(2)
Male Breast Enlargement or Mass	180	(2)
Reference	182	(1)
Suggested Readings	182	(1)
Chapter 9: Abdomen	183	(46)
History	183	(1)
General History	183	(1)
Past Medical History	184	(1)
Family History	184	(1)
Habits	184	(1)
Physical Examination	184	(5)
Order of the Examination	184	(3)
Special Maneuvers	187	(2)
Differential Diagnosis of Chief Complaints	189	(39)
Abdominal Pain	189	(18)
Nausea and Vomiting	207	(5)
Diarrhea	212	(5)
Constipation	217	(4)
Jaundice	221	(4)
Gastrointestinal Bleeding	225	(3)
References	228	(1)
Suggested Readings	228	(1)
Chapter 10: Genitourinary System	229	(31)
History	230	(1)
General History	230	(1)
Past Medical and Surgical History	230	(1)
Family History	230	(1)
Sexual History	231	(1)
Physical Examination	231	(1)
General History	231	(1)
Patterns of GU Pain	231	(1)
Diagnostic Studies	232	(5)
Laboratory Evaluation	232	(2)
Radiologic Evaluation	234	(3)
Differential Diagnosis of Chief Complaints	237	(21)
General Complaints	237	(11)
Lower Urinary Tract Symptoms	248	(8)
Urinary Incontinence	256	(2)
References	258	(1)
Suggested Readings	259	(1)
Chapter 11: Male Reproductive System	260	(29)
History	260	(2)
General History	260	(1)
Past Medical History	260	(1)
Family History	261	(1)
Sexual History	261	(1)
Habits	261	(1)
Physical Examination	262	(2)
Order of the Examination	262	(1)
Special Maneuvers	262	(2)
Differential Diagnosis of Chief Complaints	264	(24)
General Complaints	264	(13)
Erectile Function Complaints	277	(7)
Complaints Related to Male Fertility and Sexual Function	284	(4)
References	288	(1)
Chapter 12: Female Reproductive System	289	(32)
Anatomy and Physiology
Reproductive Hormones	289	(2)
History	291	(3)
General History	291	(2)
Past Medical History	293	(1)
Habits	293	(1)
Physical Examination	294	(1)
Order of the Examination	294	(1)
Differential Diagnosis of Chief Complaints	295	(24)
Mass and/or Swelling at the Introitus	295	(4)
Vaginal Discharge	299	(5)
Labial Lesions	304	(3)
Abnormal Pap Smear	307	(1)
Dysfunctional Uterine Bleeding	308	(4)
Amenorrhea	312	(3)
Dysmenorrhea	315	(1)
Ovarian Cancer	316	(2)
Sexual Dysfunction	318	(1)
Dyspareunia	319	(1)
Infertility	320	(1)
References	320	(1)
Chapter 13: Musculoskeletal System	321	(33)
Anatomy and Physiology	321	(1)
Bones and Joints	322	(1)
Assessment of Musculoskeletal Complaints	322	(1)
History	322	(2)
General Musculoskeletal History	322	(1)
Past Medical History	323	(1)
Family History	323	(1)
Habits	323	(1)
Physical Examination	324	(2)
Order of the Examination	324	(1)
Range of Motion	325	(1)
Ligamentous Tests	325	(1)
Muscle Strength and Tone	325	(1)
Special Maneuvers	326	(1)
Diagnostic Studies	326	(1)
Differential Diagnosis of Chief Complaints	326	(26)
Joint Pain	327	(1)
Polyarthralgia	327	(4)
Neck Pain	331	(4)
Low Back Pain	335	(3)
Isolated or Limited Joint Pain	338	(1)
Shoulder Pain	339	(3)
Elbow Pain	342	(1)
Wrist and Hand Pain	343	(1)
Hip Pain	344	(2)
Knee Pain	346	(3)
Ankle and Foot Pain	349	(2)
Myalgia	351	(1)
Conclusion	352	(1)
Suggested Readings	353	(1)
Chapter 14: Neurological System	354	(25)
History	354	(1)
Chief Complaint and the History of Present Illness	354	(1)
General History and the Review of Systems	354	(1)
Medical and Surgical History	355	(1)
General Neurologic History	355	(1)
Social History	355	(1)
Family History	355	(1)
Physical Examination	355	(4)
General Appearance and Affect	356	(1)
Mental Status	356	(1)
Cranial Nerve Examination	357	(1)
Motor Function	357	(1)
Reflexes	358	(1)
Coordination	358	(1)
Cerebrovascular	358	(1)
Fundoscopic Examination	359	(1)
Sensory Examination	359	(1)
Differential Diagnosis of Chief Complaints	359	(18)
Headache or Cephalalgia	359	(10)
Altered Mental Status	369	(4)
Dizziness and Vertigo	373	(4)
References	377	(1)
Suggested Readings	378	(1)
Chapter 15: Nonspecific Complaints	379	(16)
History and Physical Examination	379	(1)
Differential Diagnosis of Chief Complaints	379	(15)
Fatigue	379	(7)
Weakness	386	(3)
Fever of Unknown Origin	389	(2)
Unexplained Weight Loss	391	(3)
Suggested Readings	394	(1)
Chapter 16: Psychiatric Mental Health	395	(26)
Comprehensive Psychiatric Evaluation	396	(2)
Problem Identification and Chief Complaint	396	(1)
History of Present Illness	396	(1)
Pertinent Past Psychiatric History	396	(1)
Pertinent Social History	396	(1)
Pertinent Family History	397	(1)
Medical History and the Review of Symptoms	397	(1)
Mental Status Examination	397	(1)
Assessing for Potential Medical Mimics	398	(1)
Differential Diagnosis of Chief Complaints	398	(20)
Anxiety	398	(4)
Mood Disorders	402	(6)
Substance-Related Disorders	408	(3)
Eating Disorders	411	(3)
Thought Disorders	414	(4)
Issues Related to Older Adults	418	(1)
References	419	(1)
Suggested Readings	419	(2)
PART 3: Assessments and Differential Diagnosis with Special Patient Populations	421	(85)
Chapter 17: Pediatric Patients	422	(29)
Communicating with Infants and Children During the Pediatric Assessment	422	(1)
Infants	422	(1)
Toddlers	422	(1)
Preschoolers	423	(1)
School-Age Children	423	(1)
Adolescents	423	(1)
Pediatric History and Physical Examination	423	(13)
Head	424	(1)
Eyes	424	(1)
Ears	425	(1)
Nose and Sinuses	425	(1)
Mouth and Throat	426	(1)
Lungs	426	(1)
Heart	427	(2)
Breasts	429	(1)
Abdomen	429	(1)
Genitourinary System	430	(1)
Musculoskeletal System	431	(3)
Neurological System	434	(1)
Skin	434	(2)
Growth and Development	436	(13)
Physical Growth	436	(1)
Development by Age	437	(5)
Hearing/Speech	442	(1)
Vision	443	(1)
Nutrition	444	(2)
Anticipatory Guidance and Safety	446	(1)
Teething and Tooth Eruption	446	(3)
Suggested Readings	449	(2)
Chapter 18: Pregnant Patients	451	(26)
History	451	(1)
Physical Examination	452	(2)
Laboratory Studies	454	(1)
Prenatal Education	454	(2)
Common Chief Complaints and Discomforts of Pregnancy	456	(8)
GI Complaints	456	(2)
Abdominal Pain	458	(1)
Musculoskeletal Complaints	458	(2)
Respiratory Complaints	460	(2)
Fatigue	462	(1)
Genitourinary Complaints	462	(1)
Circulatory Complaints	463	(1)
Pregnancy Complications	464	(10)
Anemia	464	(2)
Gestational Diabetes	466	(2)
Hypertension	468	(1)
Vaginal Bleeding	469	(1)
Vaginal Infections	470	(1)
Urinary Tract Infections	471	(1)
Size Not Equal to Dates	471	(2)
Preterm Labor	473	(1)
Summary	474	(1)
References	474	(1)
Suggested Readings	475	(2)
Chapter 19: Older Patients	477	(29)
The Demographics of Aging	478	(1)
The Approach to the Assessment of Older Individuals	479	(1)
The Physiology of Aging	480	(3)
Functional Assessment	483	(6)
Measures of Function	483	(1)
Measures of Cognitive Function	483	(6)
The Atypical Presentation of Common Conditions	489	(3)
Case Analysis	490	(2)
Geriatric Syndromes	492	(2)
The Assessment of Driving Safety	494	(3)
General History	494	(1)
Focused History	494	(1)
Habits	495	(1)
Physical Examination	495	(1)
Resources	496	(1)
Head, Eyes, Ears, Nose, and Mouth	497	(1)
Neuromuscular System	498	(2)
Nutritional Assessment	500	(3)
Advance Care Planning	503	(1)
Conclusion	504	(1)
References	504	(2)
Index	506