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CHAPTER Ⅰ ROUTINE DATA1

METHODS OF PHYSICAL DIAGNOSIS1

Temperature1

Oral Temperature1

Rectal Temperature2

Pathogenesis of Fever2

Effect of Ovulation on Temperature2

Types of Fever3

Subnormal Temperature4

The Pulse4

Pulse Rate4

Pulse Tension5

Respiration6

Types of Breathing6

Blood Pressure9

Blood Pressure Technic and Equipment9

Height and Weight10

Race10

Childhood Nutrition11

Climatic Factors11

General Evolution11

Effects of Disease on Height11

Achondroplasia11

Heart Disease12

Renal Disease12

Progeria12

Ateliotic Dwarfs12

Gigantism13

Hypogonadism13

Hypergonadism13

Ovarian Insufficiency13

Weight14

Habitus14

Male and Female Body Types16

REFERENCES16

CHAPTER Ⅱ EXAMINATION OF THE HEAD17

THE CRANIUM17

Size and Shape17

Microcephalus17

Hydrocephalus17

The Acromegalic Head18

Paget＇s Disease(Osteitis Deformans)19

Craniostoses19

The Rachitic Head21

THE HAIR AND SCALP21

Alopecia21

Hirsutism(Hypertrichosis)22

THE FACE24

Dehydration of the Face24

Edema of the Face24

Color of the Face27

Anemia27

Polycythemia28

Cyanosis of the Face29

Malar Flush29

Pigmentation of the Face30

Jaundice30

Argyria30

Mask of Pregnancy(Chloasma Gravidarum)30

Hemochromatosis30

Addison＇s Disease31

Albinism(Congenital Achromodermia)32

Vitiligo32

Chrysiasis32

Local and Systemic Diseases Manifested in the Face32

Nevi(Birthmarks)32

Acne Vulgaris(Common Acne)33

Collagen Diseases34

Periarteritis Nodosa34

Disseminated Lupus Erythematosus35

Scleroderma35

The Facies of Diseases of the Endocrine Glands37

Cretinism37

Mongolian Idiocy38

Myxedema(Mucus Edema)38

Hyperthyroidism39

THE EYES39

The Eyelids43

The Conjunctiva44

Subconjunctival Hemorrhage45

The Cornea46

Corneal Sensitivity46

Keratitis46

Herpetic Lesions47

Arcus Senilis47

The Sclera48

Osteogenesis Imperfecta(Fragilitas Ossium)48

Intraocular Tension48

The Pupils48

Horner＇s Syndrome49

The Palpebral Fissures50

Exophthalmos50

Strabismus(Squint)52

Nystagmus54

The Visual Field54

THE EARS54

Color54

Contour54

Auricles54

The Auditory Canal55

Tympanic Membrane55

Mastoid Region56

Tests for Hearing56

THE NOSE56

Play of the Alae Nasi58

Intranasal Examination58

THE LIPS59

THE BUCCAL CAVITY62

Eruptions62

Pigmentation62

THE TONGUE62

Monilial Infections64

Leukoplakia(White Plaque)66

Syphilitic Lesions66

Tuberculosis of the Tongue67

Carcinoma of the Tongue67

THE TEETH AND GUMS68

Hutchinson＇s Teeth69

Hypertrophy of the Gums70

Gingivitis70

Lead Line72

THE BREATH72

THE TONSILS73

THE PHARYNX74

THE PALATE AND UVULA74

THE LARYNX75

Tuberculosis of the Larynx76

Tumors of the Larynx76

Paralysis of the Vocal Cords76

REFERENCES76

CHAPTER Ⅲ EXAMINATION OF THE NECK78

CERVICAL LYMPHADENOPATHY80

INFECTIONS81

Acute Regional Infections81

Acute Systemic Infections81

Chronic Systemic Infections82

Tuberculosis82

Sarcoidosis83

ALLERGIC REACTIONS83

Serum Sickness83

PRIMARY LYMPH NODE DISEASES83

Leukemia86

Metastatic Lymphadenopathy86

THE SALIVARY GLANDS86

Tumors of the Salivary Glands87

THE THYROID GLAND87

Anomalies of the Thyroid87

Intrathoracic(Substernal)Goiter88

Simple Goiter(Colloid Goiter)88

Toxic Goiter90

Nodular Goiters91

Thyroid Malignancy91

Acute Thyroiditis91

VASCULAR PULSATIONS IN THE NECK92

DISTENTION OF THE VEINS OF THE NECK93

REFERENCES93

CHAPTER Ⅳ EXAMINATION OF THE MUSCULOSKELETAL SYSTEM95

EXAMINATION OF THE MUSCLES95

EXAMINATION OF THE JOINTS107

The Shoulder Joint108

Motions108

Lesions109

The Elbow Joint111

The Wrist Joint113

Lesions113

The Hip Joint115

Motions116

Lesions117

The Knee Joint120

Lesions121

The Ankle Joint123

Lesions123

The Foot124

Deformities125

The Back128

Spinal Curvature128

Scoliosis129

Low Back Pain131

REFERENCES133

CHAPTER Ⅴ EXAMINATION OF THE BREASTS134

SELF-EXAMINATION134

PHYSICAL EXAMINATION135

Carcinoma138

Gynecomastia142

Tuberculosis of the Breast142

REFERENCES143

CHAPTER Ⅵ SOUNDS FROM THE THORAX：ACOUSTIC PRINCIPLES＆by S．Reid Warren，Jr Sc．D．in E．E144

SOUNDS PRODUCED IN THE THORAX145

Percussion145

Auscultation145

Electrical Pickups146

Preliminary Conclusions148

PRODUCTION AND PROPAGATION OF SOUND148

What Sound Is148

Kinds of Sounds149

Sounds in Media Other than Air151

Attenuation，Absorption and Reflection151

Reflection and Viscosity151

Attenuation and the Stethoscope152

Thoracic Sounds：Frequency Range152

Sensations of Sounds153

Loudness153

Intensity153

Physical Aspects of Hearing155

Audibility of Sounds156

Ambient Sounds157

Pitch of Sounds157

Loudness of Sounds157

Timbre157

Location of Sounds157

SOURCES OF SOUND IN THE THORAX158

Circulatory System：Loudness and Frequency Range158

Respiratory System：Loudness and Frequency Range158

Vocal Sounds158

Percussion158

Interpretation159

CONCLUSIONS159

REFERENCES160

CHAPTER Ⅶ EXAMINATION OF THE CHEST161

ROENTGENOLOGIC VERSUS PHYSICAL EXAMINATION163

INSPECTION OF THE CHEST165

Beside Inspection166

Conformation of the Normal Chest166

Size and Development of the Chest169

Asymmetry of the Chest170

Shape and Movement of the Subcostal Angle173

Local Bulging and Pulsations of the Thorax173

Abnormal Thoracic Conformation176

The Rachitic Chest176

The Long Flat Chest(Pterygoid Chest，Alar Chest)178

The Emphysematous(Barrel-Shaped)Chest179

REFERENCES181

CHAPTER Ⅷ PALPATION OF THE CHEST182

TECHNIC OF PALPATION182

VOCAL FREMITUS183

Voice Production184

Production of Fremitus184

Tactile Vibrations186

REFERENCE186

CHAPTER Ⅸ PERCUSSION OF THE CHEST187

TECHNIC OF PERCUSSION188

Diaphragmatic Excursion189

PERCUSSION SOUNDS189

Tympany189

Modified Tympany190

Metallic Ring190

Bell Tympany191

Cracked-Pot Sound191

Resonance192

Hyperresonance192

Dullness192

Flatness192

PERCUSSION RESISTANCE192

OTHER PERCUSSION METHODS192

Orthopercussion193

Auscultatory Percussion193

MOVABLE OR SHIFTING DULLNESS195

REFERENCES195

CHAPTER Ⅹ AUSCULTATION OF THE CHEST196

Effect of Posture197

The Stethoscope197

NORMAL BREATH SOUNDS197

Laryngeal or Bronchial Element of the Breath Sounds197

Vesicular Element of the Breath Sounds198

Vesicular Breath Sounds199

ABNORMAL BREATH SOUNDS200

Absent Breath Sounds200

Decreased Breath Sounds200

Exaggerated Breathing200

Bronchial Breathing200

Bronchovesicular Breathing201

Cavernous Breathing201

Amphoric Breathing201

ADVENTITIOUS SOUNDS202

Rales202

Musical Rales202

Crepitant(Consonating)Rales202

Subcrepitant(Crackling)Rales202

Bubbling(Gurgling)Rales203

Marginal(Atelectatic)Rales203

Production of Rales203

Friction Sounds204

Succussion Splash204

Metallic Tinkle204

VOICE SOUNDS205

Vocal Resonance205

Bronchophony205

Pectoriloquy205

Egophony206

REFERENCES206

CHAPTER Ⅺ PHYSICAL SIGNS IN CERTAIN DISEASES OF THE LUNGS AND PLEURA：CORRELATIVE DATA207

DISEASES OF THE LUNGS207

Pulmonary Tuberculosis207

Lobar Pneumonia207

Auscultation209

Physical Signs209

Bronchiectasis209

Bronchial Asthma210

Interstitial Emphysema211

Massive Collapse of the Lung212

Physical Signs212

Inspection212

Palpation212

Percussion212

Auscultation213

Pulmonary Embolism213

Physical Signs213

Pulmonary(Venous)Air Embolism213

Arterial Air Embolism217

DISEASES OF THE PLEURA218

Dry Pleurisy218

Inspection218

Palpation218

Percussion219

Auscultation219

Diaphragmatic Pleurisy219

Epidemic Pleurodynia(Bornholm Disease，Devil＇s Grip)219

Pleural Effusion220

Inspection220

Palpation220

Percussion220

Auscultation223

Loculated Pleural Fluid224

REFERENCES227

CHAPTER Ⅻ EXAMINATION OF THE CIRCULATORY SYSTEM228

BLOOD PRESSURE228

Normal Arterial Blood Pressure228

High Blood Pressure(Arterial Hypertension)229

Low Blood Pressure(Vascular Hypotension)229

Pulse Pressure230

Venous Blood Pressure230

THE HEART230

The Valves231

Inspection234

Palpation236

Normal Position of the Cardiac Impulse239

Displacement of the Cardiac Impulse239

Thrills240

Percussion240

Heart Size240

Method242

Cardiac Dullness245

Significance of Cardiac Dullness246

Percussion versus Roentgenology247

Auscultation251

Valve Areas251

Heart Sounds252

Origin and Characteristics of Heart Sounds252

The First Sound252

The Second Sound253

The Third Sound253

Increased Intensity of the First Sound253

Decreased Intensity of the First Sound253

Increased Intensity of the Second Sound254

Splitting or Reduplication of Heart Sounds254

Gallop Rhythm254

Heart Murmurs255

Intensity256

Cardiac Arrhythmias257

Sinus Arrhythmia258

Sinus Pauses258

Auricular and Ventricular Premature Beats258

Paroxysmal Auricular Tachycardia259

Auricular Flutter259

Auricular Fibrillation259

Paroxysmal Ventricular Tachycardia260

Ventricular Fibrillation260

Heart Block261

First Degree Heart Block261

Second Degree Block(Partial Block)261

Third Degree Block(Complete Block)261

Pulsus Alternans262

REFERENCES262

CHAPTER ⅩⅢ PHYSICAL SIGNS IN CERTAIN DISEASES OF THE HEART AND GREAT VESSELS：CORRELATIVE DATA264

VALVULAR DISEASES264

Mitral Regurgitation(Insufficiency)264

Mitral Stenosis264

Aortic Insufficiency267

Physical Signs268

Inspection268

Palpation269

Percussion271

Auscultation271

Interpretation272

Aortic Stenosis272

Physical Signs273

Inspection and Percussion273

Palpation274

Auscultation274

Tricuspid Insufficiency275

Physical Signs275

Inspection275

Palpation275

Percussion276

Auscultation276

Tricuspid Stenosis277

Pulmonary Insufficiency277

Pulmonary Stenosis277

Transmission of Murmurs277

The Continuous Murmur278

CONGENITAL CARDIAC AND VASCULAR DEFECTS279

Patent Ductus Arteriosus279

Coarctation of the Aorta279

Aberrant Right Subclavian Artery280

Interventricular Septal Defect(Roger＇s Disease)283

Eisenmenger＇s Complex283

Tetralogy of Fallot284

Patent Foramen Ovale285

MISCELLANEOUS CONDITIONS286

Pericardial Effusion286

Physical Signs286

Inspection286

Palpation288

Percussion290

Auscultation291

Cor Pulmonale291

Ayerza＇s Disease292

Xiphosternal Crunch293

REFERENCES294

CHAPTER ⅩⅣ EXAMINATION OF THE ABDOMEN295

Position of the Patient295

Regions of Abdomen295

Surface Markings296

INSPECTION OF THE ABDOMEN296

Visible Peristalsis296

Bodily Movements296

The Skin297

Rashes297

Contour297

Enlarged and Tortuous Veins298

Hirsutism and Hair Distribution298

Abdominal Pulsations298

Respiratory Movements of the Abdomen299

Abdominal Asymmetry299

Examination of the Umbilicus300

Abdominal Hernias300

Ventral Hernia300

Umbilical Hernia301

Inguinal Hernia301

Femoral Hernia302

Diaphragmatic Hernia302

PALPATION OF THE ABDOMEN302

Muscular Rigidity303

Tenderness303

Parietal Pain303

Intercostal Neuralgia304

Fluctuation304

Ascites304

Tumors305

Palpation of the Liver306

Technic307

Palpation of the Spleen307

Technic308

Palpation of the Kidneys309

PERCUSSION OF THE ABDOMEN310

AUSCULTATION OF THE ABDOMEN310

REFERENCES310

CHAPTER ⅩⅤ THE GYNECOLOGIC EXAMINATION311

EXAMINATION OF THE PATIENT311

Position of the Patient311

Position of the Examiner314

Technic314

EXTERNAL GENITALIA314

Mons Veneris315

Clitoris315

Labia Majora315

Labia Minora315

Vulva315

Bartholin＇s Glands315

Perineal Body316

Vestibule316

Urethral Meatus317

Skene＇s Ducts317

Hymen317

VAGINA AND ITS CONTENTS318

Speculum Examination318

Technic318

Cervix320

Vagina323

Vaginitis323

Vaginal Walls323

Descensus Uteri325

Palpation325

Bimanual Examination327

Uterus328

Position328

Size，Shape and Consistency328

Motion329

Adnexa330

Hydrosalpinx330

Ectopic Pregnancy330

Tumors330

Endometriosis331

Parovarian Cyst332

Parametrium332

Special Tests332

Papanicolaou Smears332

Rubin Test332

Hysterosalping-ography332

Cervical Biopsy333

Sperm Analysis333

Huhner Test333

Hanging Drop Preparations333

Tests for Gonococci333

REFERENCES333

CHAPTER ⅩⅥ EXAMINATION OF THE MALE GENITALIA，AND OF THE ANUS，RECTUM AND RECTOSIGMOID COLON334

MALE GENITALIA334

Size and Development334

Hypogonadism334

Hypergonadism334

Congenital Anomalies335

Hypospadias335

Epispadias335

Incomplete Descent of One or Both Testes335

Congenital Hydrocele335

Lesions of the Penis335

Phimosis335

Chancre335

Chancroid335

Lymphopathia Venereum(Lymphogranuloma Inguinale)337

The Testes and Scrotum338

Hydrocele339

Varicocele339

Prostate and Seminal Vesicles339

ANUS，RECTUM AND RECTOSIGMOID COLON339

Digital Examination339

Preparation339

Position339

Equipment339

Anus and Rectum340

Inspection and Palpation340

Prostate and Seminal Vesicles342

Prostate342

Carcinoma of the Prostate343

Seminal Vesicles343

Proctosigmoidoscopy344

Preparation344

Position344

Equipment345

Conduct of the Examination345

Anoscopy347

REFERENCES347

CHAPTER ⅩⅦ EXAMINATION OF THE EXTREMITIES348

NUTRITIONAL，METABOLIC AND ENDOCRINE DISORDERS MANIFESTED IN THE EXTREMITIES348

Rickets348

Pellagra349

Scurvy349

Acromegaly349

Paget＇s Disease(Osteitis Deformans)349

Gout350

THE EXTREMITIES IN CERTAIN SYSTEMIC INFECTIONS AND DEGENERATIVE STATES351

Rheumatic Fever351

Subacute Bacterial Endocarditis352

Gonococcal Arthritis352

Rheumatoid Arthritis353

(Arthritis Deformans)353

Hypertrophic Arthritis(Osteoarthritis，Senile Arthritis)353

Tuberculous Arthritis354

Tuberculous Osteomyelitis354

Syphilis354

Charcot＇s Joint355

CLUBBING OF THE FINGERS AND TOES AND HYPERTROPHIC PULMONARY OSTEOARTHROPATHY355

Symmetrical Clubbing356

Pulmonary Diseases356

Cardiac Diseases358

Hepatic and Gastrointestinal Diseases359

Unilateral Clubbing359

Unidigital Clubbing359

MISCELLANEOUS CONDITIONS359

Tetany359

Dupuytren＇s Contracture360

Volkmann＇s Ischemic Contracture360

Ganglia of the Wrist360

Carphologia360

Edema of the Extremities360

Acute Lymphangitis362

THE PERIPHERAL ARTERIES362

Palpation362

Peripheral Arteriosclerosis363

Thromboangiitis Obliterans(Buerger＇s Disease)363

Arterial Embolism363

Exposure to Cold364

Raynaud＇s Disease364

Raynaud＇s Phenomenon365

PERIPHERAL VEINS365

Varicose Veins365

Thrombophlebitis365

Phlebothrombosis366

REFERENCES366

CHAPTER ⅩⅧ NEUROLOGIC EXAMINATION367

ANATOMIC AND PHYSIOLOGIC CONSIDERATIONS367

Voluntary Motor System367

Voluntary Motor Control367

Tone368

Sensory System368

Coordination369

Special Senses369

Gnostic Functions369

Psychologic Component370

PRACTICAL METHODS OF EXAMINATION AND INTERPRETATIONS OF INDIVIDUAL FINDINGS370

Involuntary Movements370

Fibrillations(Fasciculations)370

Tremors370

Choreiform Movements371

Athetoid Movements371

Dystonic Movements371

Spasms371

Tics(Habit Spasms)372

Convulsive Seizures372

Posture，Gait and Station372

Posture372

Gait372

Station373

Meningeal Irritation374

The Head374

The Cranial Nerves374

First Nerve374

Second，Third，Fourth and Sixth Nerves375

Fifth Nerve375

Seventh Nerve376

Eighth Nerve378

Ninth Nerve380

Tenth Nerve380

Eleventh Nerve380

Twelfth Nerve381

The Neck381

The Back and Trunk382

The Extremities383

Upper Extremities383

Coordination383

Palpation of Muscles384

Atrophy of Muscles384

Muscle Strength384

Nerve Lesions384

Muscle Tone385

Reflexes385

Sensory Determination386

Lower Extremities387

Reflexes390

Coordination391

Sensory Determination392

NEUROLOGIC EVALUATION392

REFERENCES393

CHAPTER ⅩⅨ PSYCHIATRIC SURVEY394

MENTAL STATUS394

General Attitude of the Patient395

Memory395

Orientation396

Stream of Thought396

Disturbances of Perception397

Association of Ideas397

Judgment398

Mood398

Anxiety399

Apathy399

Depression399

Elation400

Other Moods400

Special Preoccupations400

Phobias，Obsessions and Compulsions400

Insight401

REFERENCES402

CHAPTER ⅩⅩ THE HISTORY403

Physician-Patient Rapport403

Use of Understandable Words404

Patient Personalities404

TECHNIC OF HISTORY TAKING404

History of Present Illness405

Systemic Review405

Past Medical History406

Occupational History406

Social History407

Family History407

REFERENCES407

INDEX409