01. History and Physical Examination | Clinicians Pocket Reference, 11th Edition

Print Close Window

Note: Large images and tables on this page may necessitate printing in landscape mode.

Copyright 2007 The McGraw-Hill Companies. All rights reserved.

Clinician's Pocket Reference > Chapter 1. History and Physical Examination >

History and Physical Examination

See an example of a complete H&P write-up. The details and length of a written H&P can vary with the particular problem and with the service to which the patient is admitted.

History

Identification: Name, age, sex, referring physician, informant (eg, patient, relative, old chart), and reliability of the informant.

Chief Complaint: State, in patient's words, the current problem.

History of the Present Illness (HPI): Define the present illness by quality; quantity; setting; anatomic location and radiation; time course, including when the illness began; whether the complaint is progressing, regressing, or steady; whether the complaint is of constant or intermittent frequency; and aggravating, alleviating, and associated factors. The information should be in chronologic order, including diagnostic tests done before admission. Record related history, including previous treatment for the problem, risk factors, and pertinent negative results. Include family history and psychosocial history pertinent to the chief complaint. Other significant ongoing problems should be included in the HPI in a separate section or paragraph. For instance, if a patient with poorly controlled diabetes mellitus comes to the emergency department because of chest pain, the HPI should first include information regarding the chest pain followed by a detailed history of the diabetes mellitus. If the diabetes mellitus is diet controlled or otherwise well controlled, the history of the diabetes mellitus may be placed in the past medical history.

Past Medical History (PMH): Current medications, including OTC medications, vitamins, and herbal agents; allergies (drug and other, as well as specific allergy manifestations); operations; hospitalizations; blood transfusions, including when and how many units and the type of blood product; trauma; and stable current and past medical problems unrelated to the HPI. Adult patients: Ask about diabetes mellitus; HTN; MI; stroke; PUD; asthma; emphysema; thyroid, liver, and kidney disease; bleeding disorders; cancer; TB; hepatitis; and STDs. Also ask about routine health maintenance. The questions for this category depend on the age and sex of the patient but can include last Pap smear and pelvic exam; breast exam; whether the patient does breast self-examinations; date of last mammogram; diphtheria/tetanus immunization; pneumococcal, influenza, and hepatitis B vaccines; stool samples for occult blood; sigmoidoscopy or colonoscopy; cholesterol; HDL cholesterol; functioning smoke alarms on each floor at home; and use of seat belts. Pediatric patients: Include prenatal and birth history, feedings, food intolerance, immunization history, hot water heater temperature setting, and use of bicycle helmets.

Family History: Age, status (alive, dead) of blood relatives and medical problems of blood relatives (ask about cancer, especially breast, colon, and prostate; TB, asthma; MI; HTN; thyroid disease; kidney disease; PUD; DM; bleeding disorders; glaucoma, macular degeneration; and depression and alcohol or substance abuse). Write out or use a family tree (see Figure in example of a complete H&P write-up).

Psychosocial (Social) History: Stressors (financial, significant relationships, work or school, health) and support (family, friends, significant other, clergy); lifestyle risk factors (alcohol, drugs, tobacco, and caffeine use; diet; exercise; exposure to environmental agents; and sexual practices); patient profile (may include marital status and children, sexual orientation; present and past employment; financial support and insurance; education; religion; hobbies; beliefs; living conditions); for veterans include military service history. Pediatric patients: Include grade in school and sleep and play habits.

Review of Systems (ROS)

General: Weight loss, weight gain, fatigue, weakness, appetite, fever, chills, night sweats

Skin: Rashes, pruritus, bruising, dryness, skin cancer or other lesions

Head: Trauma, headache, tenderness, dizziness, syncope

Eyes: Vision, changes in visual field, glasses, last prescription change, photophobia, blurring, diplopia, spots or floaters, inflammation, discharge, dry eyes, excessive tearing, history of cataracts or glaucoma

Ears: Hearing changes, tinnitus, pain, discharge, vertigo, history of ear infections

Nose: Sinus problems, epistaxis, obstruction, polyps, changes in or loss of sense of smell

Throat: Bleeding gums; dental history (last checkup, etc); ulcerations or other lesions on tongue, gums, buccal mucosa

Respiratory: Chest pain; dyspnea; cough; amount and color of sputum; hemoptysis; history of pneumonia, influenza and pneumococcal vaccinations, TB exposure and positive PPD

Cardiovascular: Chest pain, orthopnea, trepopnea, dyspnea on exertion, PND, murmurs, claudication, peripheral edema, palpitations

Gastrointestinal: Abdominal pain, dysphagia, heartburn, nausea, vomiting, diarrhea, constipation, hematemesis, indigestion, melena (hematochezia), hemorrhoids, change in stool shape and color, jaundice, fatty food intolerance

Gynecologic: Gravida/para/abortions; age at menarche; last menstrual period (frequency, duration, flow); dysmenorrhea; spotting; menopause; contraceptive method; sexual history, including history of venereal disease, frequency of intercourse, number of partners, sexual orientation and satisfaction, and dyspareunia

Genitourinary: Frequency, urgency, hesitancy; dysuria; hematuria; polyuria; nocturia; incontinence; venereal disease; discharge; sterility; impotence; polyuria; polydipsia; change in urinary stream; and sexual history, including frequency of intercourse, number of partners, sexual orientation and satisfaction, and history of STD

Endocrine: Polyuria, polydipsia, polyphagia, temperature intolerance, glycosuria, hormone therapy, changes in hair or skin texture

Musculoskeletal: Arthralgia, arthritis, trauma, joint swelling, redness, tenderness, limitations in ROM, back pain, musculoskeletal trauma, gout

Peripheral Vascular: Varicose veins, intermittent claudication, history of thrombophlebitis

Hematology: Anemia, bleeding tendency, easy bruising, lymphadenopathy

Neuropsychiatric: Syncope; seizures; weakness; ataxia or coordination problems; alterations in sensations, memory, mood, or sleep pattern, anhedonia, loss of energy, decreased ability to concentrate, change in weight or appetite, family history of depression or suicide; emotional disturbances; drug and alcohol problems

Physical Examination

General: Mood, stage of development, race, and sex. State if patient is in distress or is assuming an unusual position, such as sitting up leaning forward (position often seen in patients with acute exacerbation of COPD or pericarditis). Note if patient appears markedly older or younger than stated age.

Vital Signs: Temperature (note if oral, rectal, axillary or ear), pulse, respirations, BP (may include right arm, left arm, lying, sitting, standing; see Table 1 3), height, weight and BMI (weight in kilograms / [height in meters]²). Always include BP and heart rate supine and after the patient has been standing 1 min if volume depletion (GI bleeding, pancreatitis, diarrhea, or vomiting) or autonomic insufficiency is suspected, especially if the patient reports dizziness or syncope.

Skin: Rashes, eruptions, scars, tattoos, moles, hair pattern (See Dermatologic Descriptions for definitions of dermatologic lesions.)

Lymph Nodes: Location (head and neck, supraclavicular, epitrochlear, axillary, inguinal), size, tenderness, motility, consistency

Head, Eyes, Ears, Nose, and Throat (HEENT)

Head: Size and shape, tenderness, trauma, bruits. Pediatric patients: Fontanels, suture lines

Eyes: Conjunctiva; sclera; lids; position of eyes in orbits; pupil size, shape, reactivity; extraocular muscle movements; visual acuity (eg, 20/20); visual fields; fundi (disc color, size, margins, cupping, spontaneous venous pulsations, hemorrhages, exudates, A V ratio, nicking)

Ears: Hearing test; tenderness, discharge, external canal, tympanic membrane (intact, dull or shiny, bulging, motility, fluid or blood, injected)

Nose: Symmetry; palpation over frontal, maxillary, and ethmoid sinuses; inspection for obstruction, lesions, exudate, inflammation. Pediatric patients: Nasal flaring, grunting

Throat: Lips, teeth, gums, tongue, pharynx (lesions, erythema, exudate, tonsillar size, presence of crypts)

Neck: ROM, tenderness, JVD, lymph nodes, thyroid examination, location of larynx, carotid bruits, HJR. Record JVD in relation to the number of centimeters above or below the sternal angle, such as "1 cm above the sternal angle," rather than "no JVD."

Chest: Configuration and symmetry of movement with respiration; intercostal retractions; palpation for tenderness, fremitus, and chest wall expansion; percussion (include diaphragmatic movement between tidal breathing and full inspiration); breath sounds; adventitious sounds (rales, rhonchi, wheezes, rubs). If indicated: vocal fremitus, whispered pectoriloquy, egophony (found with consolidation)

Heart: Rate, inspection, and palpation of precordium for point of maximal impulse, apical impulse, and thrills; auscultation at the apex, LLSB, and right and left second intercostal spaces with diaphragm and apex and LLSB with bell. Also at the apex with bell with patient in the left lateral decubitus position and at the third and fourth intercostal spaces with diaphragm with the patient sitting up, leaning forward, and fully exhaled. (For a description of S₁ and S₂ and where best to hear the heart sounds, see legend for Figure 1 1.)

Breast: Inspection for nipple discharge, inversion, excoriations and fissures, and skin dimpling or flattening of the contour; palpation for masses, tenderness; gynecomastia in men and boys

Abdomen: Shape (scaphoid, flat, distended, obese); examination for scars; auscultation for bowel sounds and bruits; percussion for tympani and masses; liver size (span in midclavicular line); CVA tenderness; palpation for tenderness (if present, check for rebound tenderness); ascites, hepatomegaly, splenomegaly; guarding, inguinal adenopathy

Male Genitalia: Inspection for penile lesions, scrotal swelling, testicles (size, tenderness, masses, varicocele), and hernia; transillumination of testicular masses

Pelvic (Women and Girls): See Chapter 13.

Rectal: Inspection and palpation for hemorrhoids, fissures, skin tags, sphincter tone, masses; presence or absence of stool; test stool for occult blood; in men grade prostate size from small (1+) to massively enlarged (4+); note nodules, tenderness

Musculoskeletal: Amputations, deformities, visible joint swelling, and ROM; palpation of joints for swelling, tenderness, and warmth

Peripheral Vascular: Hair pattern; color change of skin; varicosities; cyanosis; clubbing; palpation of radial, ulnar, brachial, femoral, popliteal, posterior tibial, dorsalis pedis pulses; simultaneous radial pulses; calf tenderness; Homans sign; edema; auscultation for femoral bruits

Neurologic

Mental Status Examination: (If appropriate, see sections Psychiatric History and Physical, and Psychiatric Mental Status Examination.)

Cranial Nerves: There are 12 cranial nerves, the functions of which are as follows:

I Olfactory Smell
II Optic Vision, visual fields, and fundi; afferent limb of pupillary response
III, IV, VI Oculomotor, trochlear, abducens Efferent limb pupillary response, ptosis, volitional eye movements, pursuit eye movements
V Trigeminal Corneal reflex (afferent), facial sensation; test masseter and temporalis muscle by having patient bite
VII Facial Raise eyebrows, close eyes tight, show teeth, smile, or whistle, corneal reflex (efferent)
VIII Acoustic Hearing; test by watch tick, finger rub, Weber Rinne test (see also Physical Signs, Symptoms, and Eponyms) if hearing loss noted on history or gross testing. (Air conduction lasts longer than bone conduction in a healthy person.)
IX, X Glossopharyngeal and vagus Gag reflex; speech. Palate should move upward in midline
XI Spinal accessory Shoulder shrug, push head against resistance
XII Hypoglossal Tongue movement. Test strength by having the patient press tongue against the buccal mucosa on each side while you press a finger against the patient's cheek. Observe for fasciculations.

Motor: Test strength in upper and lower extremities proximally and distally. (Grading system: 5, active motion against full resistance; 4, active motion against some resistance; 3, active motion against gravity; 2, active motion with gravity eliminated; 1, barely detectable motion; 0, no motion or muscular contraction detected)

Cerebellum: Romberg test (see Physical Signs, Symptoms, and Eponyms). Heel to shin (should not be with assistance from gravity; instruct a patient sitting with legs dangling to drag the heel of one foot up the shin of the other leg and not down the shin), finger to nose, heel-and-toe walking, rapid alternating movements of upper and lower extremities

Sensory: Pain (sharp) or temperature of distal and proximal upper and lower extremities, vibration using either a 128- or 256-Hz tuning fork or position sense of distal parts of upper and lower extremities, and stereognosis or graphesthesia. Identify deficits using dermatome and cutaneous innervation diagrams (Figure 1 2).

Reflexes: Brachioradialis and biceps C5 6, triceps C7 8, abdominal (upper T8 10, lower T10 12), quadriceps (knee) L3 5, ankle S1 2. (Grading system: 4+, hyperactive with clonus; 3+, brisker than usual; 2+, normal or average; 1+, decreased or less than normal; 0, absent). Check for pathologic reflexes: Babinski sign, Hoffmann sign, snout, others (see Physical Signs, Symptoms, and Eponyms). Pediatric patients: Moro reflex (startle) and suck reflexes

Figure 1 1.

Graphic representation of common heart murmurs. Table 1 2 shows abbreviations and descriptions. Height of box indicates intensity of heart sound; hatched lines indicate pattern of murmur. S₁: Occurs at beginning of systole and is closure of the mitral (M₁) and tricuspid (T₁) valves. Normally, T₁ is heard only at the LLSB. S₁ is loudest at the apex. S₂: Occurs at end of systole and is closure of the aortic (A₂) and pulmonic valves (P₂). P₂ is best heard at the L second ICS. S₂ is loudest at R second ICS. The L second ICS is where to listen for splitting of A₂ and P₂. At end inspiration with tidal breathing there is more pronounced splitting of the A₂ and P₂ sounds (they are farther apart than at end expiration). With normal physiology M₁ occurs before T₁; A₂ occurs before P₂.

Figure 1 2.

A: Dermatomes and cutaneous innervation patterns, anterior view. (Reproduced, with permission, from: Aminoff MJ et al [eds]: Clinical Neurology, 6th ed, McGraw-Hill, 2005.)

B: Dermatomes and cutaneous innervation patterns, posterior view. (Reproduced, with permission, from: Aminoff MJ et al [eds]: Clinical Neurology, 6th ed, McGraw-Hill, 2005.)

Database

Laboratory tests, imaging and other available information.

Problem List

(See Example of a Written History and Physical Examination.) Include entry date of problem, date of problem onset, problem number. (In the initial problem list, number the problems in order of their severity. After the initial list is generated, add problems chronologically.) List problem by status: active or inactive.

Assessment

Discussion with a differential diagnosis of each current problem followed by the plan for each problem. The assessment is more than a listing of problems.

Plan

Additional laboratory and diagnostic tests, medical treatment, consults, etc. Note: Legibly sign the H&P, and note your title. Record the date and time with each entry.

Psychiatric History and Physical Examination

The elements of the psychiatric history and physical are identical to those of the basic H&P. The main difference involves attention to the past psychiatric history and a more detailed mental status examination as described in the following section.

Psychiatric Mental Status Examination

The following factors are evaluated as part of the psychiatric status examination.

Appearance: Gestures, mannerisms, etc
Speech: Coherence, flight of ideas, etc
Mood and Affect: Depression, elation, anger, etc
Thought Process: Blocking, evasion, etc
Thought Content: Worries, hypochondriasis, lack of self-confidence, delusions, hallucinations, etc
Motor Activity: Slow, rapid, purposeful, etc
Cognitive Functions:
Attention and concentration
Memory (immediate, recent, and remote recall)
Calculations
Abstractions
Judgment

Folstein Mini-Mental State Examination

Perform a thorough mental status exam on every geriatric patient, patient with AIDS, and patient with suspected dementia. The Mini-Mental State Exam is a quick and simple test, and the results can be followed over time for assessment of progression, improvement, or no changes in the underlying process. The Mini-Mental State Exam (Folstein et al: J Psychiatr Res 1975;12:189) is divided into two sections: one assessing orientation, memory, and attention, and the other testing the patient's ability to write a sentence and copy a diagram (usually two pentagons that intersect to form a four-sided figure). Table 1 1 shows the Mini-Mental State Exam.

Table 1 1 The Mini-Mental State Examination

Patient ____________________________
Examiner ___________________________
Date ______________________________
"Mini-Mental State"
Maximum Score	Score
		Orientation
5		What is the (year) (season) (date) (day) (month)?
5		Where are we? (state) (county) (town) (hospital) (floor)
		Registration
3		Name 3 objects: 1 second to say each. Then ask the patient all 3 after you have said them. Give 1 point for each correct answer. Then repeat until he learns all 3. Count trials and record. Trials_______________________________
		Attention and Calculation
5		Serial 7's: One point for each correct. Stop after 5 answers. Alternatively, spell "world" backward.
		Recall
3		Ask for the 3 objects repeated above. Give 1 point for each correct answer.
		Language
9		Point to a pencil, and watch and ask the patient to name it. (2 points)
		Repeat the following: "No if's, and's, or but's." (1 point)
		Follow a 3-stage command: "Take a paper in your right hand, fold it in half, and put it on the floor." (3 points)
		Read and obey the following:
		Close your eyes	(1 point)
		Write a sentence	(1 point)
		Copy design (two intersecting pentagrams)	(1 point)
__________________ Total Score
Assess level of consciousness along the following continuum
Alert Drowsy Stupor Coma

Source: Based on data from: Folstein, Folstein, and McHugh: J Psychiatr Res 1975;12:189 198. Used with permission.

Heart Murmurs and Extra Heart Sounds

Table 1 2 and Figure 1 1 describe the various types of murmurs and extra heart sounds.

Table 1 2 Heart Murmurs and Extra Heart Sounds^a

Type^b	Description
A. Aortic stenosis (AS)	Heard best at second intercostal space. Systolic (medium-pitched) crescendo decrescendo murmur with radiation to the carotid arteries. A₂ decreased, ejection click and S₄ often heard at apex. Paradoxical splitting of S₂. Narrow pulse pressure and delayed carotid upstroke and left ventricular hypertrophy (LVH) with lift at apex.
B. Aortic insufficiency (AI)	Heard best at left lower sternal border at third and fourth interspace with patient sitting up, leaning forward and fully exhaled. Diastolic (high-pitched) decrescendo murmur. Often with LVH. Widened pulse pressure, bisferious pulse, Traube sign, Quincke sign, and Corrigan pulse may be seen with chronic aortic insufficiency. S₃ and pulsus alternans often present with acute aortic insufficiency.
C. Pulmonic stenosis (PS)	Heard best at left second intercostal space. Systolic crescendo decrescendo murmur. Louder with inspiration. Click often present. P₂ delayed and soft if severe. Right ventricular hypertrophy (RVH) with parasternal lift.
D. Pulmonic insufficiency (PI)	Heard best at left second intercostal space. Diastolic decrescendo murmur. Louder with inspiration. RVH usually present.
E. Mitral stenosis (MS)	Localized at the apex. Diastolic (low-pitched rumbling sound) murmur heard best with the bell in the left lateral decubitus position. With increased or decreased S₁. Opening snap (OS) heard best at apex with diaphragm. Increased P₂, right-sided S₄, left-sided S₃ often present. RVH with parasternal lift may be present.
F. Mitral insufficiency (MI)	Heard best at apex. Holosystolic (high-pitched) murmur with radiation to axilla. Soft S₁, may be masked by murmur. S₃ and LVH often present. Midsystolic click suggests mitral valve prolapse.
G. Tricuspid insufficiency (TI)	Heard best at left lower sternal border. Holosystolic (high-pitched) murmur. Increases with inspiration. Right-sided S₃ often present. Large V wave in jugular venous pulsations.
H. Atrial septal defect (ASD)	Heard best at left upper sternal border. Systolic (medium-pitched) murmur. Fixed splitting of S₂ and RVH, often with left- and right-sided S₄.
I. Ventricular septal defect (VSD)	Heard best at left lower sternal border. Harsh holosystolic (high-pitched) murmur. S₁ and S₂ may be soft.
J. Patent ductus arteriosus (PDA)	Heard best at left first and second intercostal space. Continuous, machinery (medium-pitched) murmur. Increased P₂ and ejection click may be present.
K. Third heart sound (S₃)	Early diastolic sound caused by rapid ventricular filling. Heard best with bell. Left-sided S₃ heard at apex, right-sided S₃ heard at left lower sternal border. Left-sided S₃ seen normally in young people, also pregnancy, thyrotoxicosis, mitral regurgitation, and congestive heart failure.
L. Fourth heart sound (S₄)	Late diastolic sound caused by a noncompliant ventricle. Heard best with bell. Left-sided S₄ heard at apex, right-sided S₄ heard at left lower sternal border. Left-sided S₄ seen with hypertension, aortic stenosis, and myocardial infarction. Right-sided S₄ seen with pulmonic stenosis and pulmonary hypertension.

^aRefer to Figure 1 1 for graphic representations of murmurs.

^b Capital letters preceding type of murmur refer to graphs in Figure 1 1.

Blood Pressure Guidelines

There is a clear association between HTN and coronary artery and cerebrovascular diseases. Hypertension is defined as systolic BP > 140 mm Hg or diastolic BP > 90 mm Hg in adults. Measure BP after 5 min of rest with patient seated, feet resting on the floor and arm at heart level. Use the stethoscope bell (the last sounds heard are the Korotkoff sounds, which are low pitched). Take the average of two readings separated by 2 min. Elevated readings on three separate days are required for a diagnosis of HTN. Classification and measurement guidelines for adults are shown in Table 1 3.

Table 1 3 Guidelines for Blood Pressure Management in Adults Based on JNC7

Classification of Blood Pressure (BP)
Category	SBP (mmHg)		DBP (mmHg)
Normal	<120	and	<80
Prehypertension	120 139	or	80 89
Hypertension, stage 1	140 159	or	90 99
Hypertension, stage 2	160	or	100

Blood Pressure Measurement Techniques
Method	Notes
In-office	Two readings, 5 min apart, sitting in chair. Confirm elevated reading in contralateral arm
Ambulatory BP monitoring	Indicated for evaluation of "white coat hypertension." Absence of 10 20% BP decrease during sleep may indicate increased cardiovascular disease risk
Patient self-check	Provides information on response to therapy. May help improve adherence to therapy and is useful for evaluating "white coat hypertension."

SBP = systolic blood pressure; DBP = diastolic blood pressure

The National High Blood Pressure Education Program is administered by the National Heart, Lung and Blood Institute (NHLB) at the National Institutes of Health. Copies of the JNC7 Report are available at the NHLB Website at http://www.nhlbi.nih.gov. NIH Publication 03 5233, May 2003. The National High Blood Pressure Education Program is administered by the National Heart, Lung and Blood Institute (NHLB) at the National Institutes of Health. Copies of the JNC7 Report are available at the NHLB Website at http://www.nhlbi.nih.gov. NIH Publication 03 5233, May 2003.

In children 1 10 y old, systolic BP can be calculated as follows: Lower limits (fifth percentile): 70 mm Hg + (child's age in years x 2); typical (fiftieth percentile): 90 mm Hg + (child's age in years x 2).

Dental Examination

The dental examination is an often overlooked part of the general H&P. The patient may have an intraoral problem contributing to the overall medical condition (ie, inability to eat because of a toothache, abscess, or ill-fitting denture in a patient with poorly controlled diabetes) for which a dental consult may be necessary. Loose dentures can compromise manual maintenance of an open airway. In addition, in an emergency situation in which intubation is necessary, complications can occur if the clinician is unfamiliar with the oral structures.

The patient may be able to give some dental history, including recent toothaches, abscesses, and loose teeth or dentures. Be sure to ask whether the patient is wearing a removable partial denture (partial plate), which should be removed before intubation. Because lost dentures are a chief dental complaint of hospitalized patients, take care not to misplace the removed prosthesis.

Perform a brief dental examination with gloved hand, two tongue blades, and a flashlight. Look for obvious inflammation, erythema, edema, or ulceration of the gingiva (gums) and oral mucosa. Gently tap on any natural teeth to test for sensitivity. Place each tooth between two tongue blades and push gently to check for looseness. This step is especially important for the maxillary anterior teeth, which serve as the fulcrum for the laryngoscope blade. Note abnormal dental findings and request the appropriate consults. Many diseases, including AIDS, STDs, pemphigus, pemphigoid, allergies, uncontrolled diabetes, leukemia, and others, may first manifest themselves in the mouth.

Hospitalized patients often have difficulty cleaning their teeth or dentures. Add this care to the daily orders if indicated. Patients who will be receiving head and neck radiation must be examined and treated for any tooth extractions or dental infections before initiation of radiation therapy. Extractions after radiation to the maxilla and particularly the mandible can lead to osteoradionecrosis, a condition that can be impossible to control.

Eruption of Teeth

The eruption of teeth may be of great concern to new parents. Parents often think something is developmentally wrong with a child if teeth have not appeared by a certain age.

The timing of tooth eruption varies tremendously. Factors contributing to this variation include family history, ethnic background, vitality during fetal development, position of teeth in the arch, size and shape of the dental arch itself, and, in the case of the eruption of permanent teeth, the time at which the primary tooth was lost. Radiographs of the maxilla and mandible show whether the teeth are present. Figure 1 3 is a guide to the chronology of tooth eruption. Remember that variations may be greater than 1 y in some cases.

Figure 1 3.

Dentition development sequences. There can be wide variation in the age when teeth shed and erupt. (Based on data from: McDonald RE, Avery DR [eds]: Dentistry for the Child and Adolescent, Mosby, St. Louis, 1994. Used with permission.)

Dermatologic Descriptions

Atrophy: Thinning of the surface of the skin with associated loss of normal markings. Examples: Aging, striae associated with obesity, scleroderma

Bulla: A superficial, well-circumscribed, raised, fluid-filled lesion greater than 1 cm in diameter. Examples: Bullous pemphigoid, pemphigus, dermatitis herpetiformis

Burrow: A subcutaneous linear track made by a parasite. Example: Scabies

Crust: A slightly raised lesion with irregular border and variable color resulting from dried blood, serum, or other exudate. Examples: Scab resulting from an abrasion, impetigo

Ecchymosis: A flat, nonblanching, red-purple-blue lesion that results from extravasation of red blood cells into the skin. Differs from purpura in size; ecchymoses are large purpura lesions. Examples: Trauma, long-term steroid use

Erosion: A depressed lesion resulting from loss of epidermis due to rupture of vesicles or bullae. Example: Rupture of herpes simplex blister

Excoriation: A linear superficial lesion, which may be covered with dried blood. Early lesions with surrounding erythema. Often self-induced. Example: Scratching associated with pruritus from any cause

Fissure: A deep linear lesion into the dermis. Example: Cracks seen in athlete's foot

Keloid: Irregular, raised lesion resulting from hypertrophied scar tissue. Examples: Often seen with burns; African Americans are more prone to keloid formation than are other people

Lichenification: A thickening of the skin with an increase in skin markings resulting from chronic irritation and rubbing. Example: Atopic dermatitis

Macule: A circumscribed nonpalpable discoloration of the skin less than 1 cm in diameter. Examples: Freckles, rubella, petechiae

Nodule: A solid, palpable, circumscribed lesion larger than a papule and smaller than a tumor. Examples: Erythema nodosum, gouty tophi

Papule: A solid elevated lesion less than 1 cm in diameter. Examples: Acne, warts, insect bites

Patch: A nonpalpable discoloration of the skin with an irregular border, greater than 1 cm in diameter. Example: Vitiligo

Petechiae: Flat, pinhead-sized, nonblanching, red purple lesions caused by hemorrhage into the skin. Example: Seen in DIC, ITP, SLE, meningococcemia (Neisseria meningitidis)

Plaque: A solid, flat, elevated lesion greater than 1 cm in diameter. Examples: Psoriasis, discoid lupus erythematosus, actinic keratosis

Purpura: A condition characterized by flat, nonblanching, red purple lesions larger than petechiae caused by hemorrhage into the skin. Examples: Henoch Sch nlein purpura, TTP

Pustule: A vesicle filled with purulent fluid. Examples: Acne, impetigo

Scales: Partial separation of the superficial layer of skin. Examples: Psoriasis, dandruff

Scar: Replacement of normal skin with fibrous tissue, often resulting from injury. Examples: Surgical scar, burn

Telangiectasia: Dilatation of capillaries resulting in red, irregular, clustered lines that blanch. Examples: Seen in scleroderma, Osler Weber Rendu disease, cirrhosis

Tumor: A solid, palpable, circumscribed lesion greater than 2 cm in diameter. Example: Lipoma

Ulcer: A depressed lesion resulting from loss of epidermis and part of the dermis. Examples: Decubitus ulcers, primary lesion of syphilis, venous stasis ulcer

Vesicle: A superficial, well-circumscribed, raised, fluid-filled lesion that is less than 1 cm in diameter. Examples: Herpes simplex, varicella (chickenpox)

Wheal: Slightly raised, red, irregular, transient lesions secondary to edema of the skin. Examples: Urticaria (hives), allergic reaction to injections or insect bites

Dermatome and Cutaneous Innervation

Figures 1 2 A and B show dermatome levels and cutaneous innervation distribution useful in the physical examination.

Physical Signs, Symptoms, and Eponyms

Allen Test: (See Chapter 13.)

Apley Test; Apley Grind Test: Determination of meniscal tear in the knee by grinding the joint manually

Argyll Robertson Pupil: Bilaterally small, irregular, unequal pupils that react to accommodation but not to light. Seen with tertiary syphilis

Auspitz Sign: Pinpoint bleeding after removal of a psoriasis scale

Austin Flint Murmur: Late diastolic mitral murmur; associated with aortic insufficiency with a normal mitral valve

Babinski Sign: Extension of the large toe with stimulation of the plantar surface of the foot instead of the normal flexion; indicative of upper motor neuron disease (normal in neonates)

Bainbridge Reflex: Increased heart rate due to increased right atrial pressure

Battle Sign: Ecchymosis behind the ear associated with basilar skull fractures

Beau Lines: Transverse depressions in nails due to previous systemic disease

Beck Triad: JVD, diminished or muffled heart sounds, and decreased BP associated with cardiac tamponade

Bell Palsy: Lower motor neuron lesion of the facial nerve affecting muscles of upper and lower face. Easily distinguished from upper motor lesions, which predominately affect muscles of the lower face because upper motor neurons from each side innervate muscles on both sides of the upper part of the face

Bergman Triad: Altered mental status, petechiae, and dyspnea associated with fat embolus syndrome

Biot Breathing: Abruptly alternating apnea and equally deep breaths (seen with brain injury)

Bisferious Pulse: Double-peaked pulse seen in severe chronic aortic insufficiency

Bitot Spots: Small scleral white patches suggesting vitamin A deficiency

Blumberg Sign: Pain felt in the abdomen when steady constant pressure is quickly released (seen with peritonitis)

Blumer Shelf: Palpable hardness on rectal examination, due to metastatic cancer of the rectouterine pouch (pouch of Douglas) or rectovesical pouch

Bouchard Nodes: Hard, nontender, painless nodules in the dorsolateral aspects of the proximal interphalangeal joints associated with osteoarthritis, caused by hypertrophy of the bone

Branham Sign: Abrupt slowing of the heart rate with compression of the feeding artery (seen with large A V fistulas)

Brudzinski Sign: Flexion of the neck causing flexion of the hips (seen in meningitis)

Chadwick Sign: Bluish color of cervix and vagina, seen with pregnancy

Chandelier Sign: Extreme pain elicited with movement of the cervix during bimanual pelvic examination (indicates PID)

Charcot Triad: Right upper quadrant pain, fever and chills, and jaundice associated with cholangitis

Cheyne Stokes Respiration: Repeating cycle of a gradual increase in depth of breathing followed by a gradual decrease to apnea (seen with CNS disorders, uremia, some normal sleep patterns)

Chvostek Sign: Facial spasm elicited by tapping over the facial nerve, indicating hypocalcemia (tetany). May be normal finding in some patients

Corrigan Pulse: Palpable hard pulse immediately followed by sudden collapse (seen in aortic regurgitation)

Cullen Sign: Ecchymosis around the umbilicus associated with severe intraperitoneal bleeding (seen with ruptured ectopic pregnancy and hemorrhagic pancreatitis)

Cushing Triad: HTN, bradycardia, and irregular respiration associated with increased intracranial pressure

Darier Sign: Erythema and edema elicited by stroking of the skin, indicating mastocytosis

Doll Eyes: Conjugated movement of eyes of comatose patients in one direction as head is briskly turned in the other direction. Tests oculocephalic reflex indicating intact brain stem

Drawer Sign: Forward (or backward) movement of the tibia with pressure, indicating laxity or a tear in the anterior (or posterior) cruciate ligament

Dupuytren Contracture: Proliferation of fibrosis tissue of the palmar fascia resulting in contracture of the fourth and/or fifth digits; often bilateral. May be hereditary or seen in patients with chronic alcoholic liver disease or seizures

Duroziez Sign: To-and-fro murmur when stethoscope is pressed over the femoral artery, indicating aortic regurgitation

Electrical Alternans: Beat-to-beat variation in the electrical axis (seen in large pericardial effusions), suggesting impending hemodynamic compromise

Ewart Sign: Dullness to percussion, increased fremitus and bronchial breathing beneath the angle of the left scapula, indicating pericardial effusion

Fong Lesion/Syndrome: Autosomal-dominant anomalies of the nails and patella associated with renal abnormalities

Frank Sign: Fissure of the ear lobe; may be associated with CAD, DM, and HTN

Gibbus: Angular convexity of the spine due to vertebral collapse (associated with osteoporosis or metastasis)

Gregg Triad: Cataracts, heart defects, and deafness with congenital rubella

Grey Turner Sign: Ecchymosis in the flank associated with retroperitoneal hemorrhage

Grocco Sign: Triangular area of paravertebral dullness, opposite side of a pleural effusion

Heberden Nodes: Hard, nontender, painless nodules on the dorsolateral aspects of the distal interphalangeal joints associated with osteoarthritis. Results from hypertrophy of the bone

Hegar Sign: Softening of the distal uterus. Reliable early sign of pregnancy

Hollenhorst Plaque: Cholesterol plaque on retina seen on funduscopic examination (associated with amaurosis fugax)

Hill Sign: Femoral artery pressure 20 mm Hg greater than brachial pressure (seen in severe aortic regurgitation)

Hoffmann Sign/Reflex: Flicking of the volar surface of the distal phalanx causing fingers to flex (associated with pyramidal tract disease)

Homan Sign: Calf pain with forcible dorsiflexion of the foot (associated with DVT)

Horner Syndrome: Unilateral miosis, ptosis, and anhidrosis (absence of sweating). From destruction of ipsilateral superior cervical ganglion often from lung carcinoma, especially squamous cell carcinoma

Janeway Lesion: Erythematous or hemorrhagic lesion seen on the palm or sole with subacute bacterial endocarditis

Joffroy Reflex: Inability to wrinkle the forehead when bending head and looking up (seen in hyperthyroidism)

Kayser Fleischer Ring: Brown pigment lesion due to copper deposition (seen in Wilson disease)

Kehr Sign: Left shoulder and left upper quadrant pain associated with splenic rupture

Kernig Sign: Inability to completely extend the leg when the thigh is flexed at a right angle, caused by inflammation of the meninges (seen with meningitis)

Koplik Spots: White papules on buccal mucosa opposite molars (seen in measles)

Korotkoff Sounds: Low-pitched sounds resulting from vibration of the artery, detected when measuring BP with the bell of a stethoscope. The last Korotkoff sound is a more accurate estimate of the true diastolic BP than is diastolic BP measured with the diaphragm.

Kussmaul Respiration: Deep, rapid respiratory pattern (seen in coma or DKA)

Kussmaul Sign: Paradoxical increase in jugular venous pressure on inspiration (seen in constrictive pericarditis, mediastinal tumor, right ventricular infarction, acute cor pulmonale, and congestive heart failure)

Kyphosis: Excessive rounding of the thoracic spinal convexity, associated with aging, especially in women

Las gue Sign/Straight-Leg-Raising Sign: Pain in the distribution of nerve root when a patient extended in the supine position raises the leg gently; suggests lumbar disk disease.

Levine Sign: Clenched fist over the chest while describing chest pain (associated with angina and AMI)

Lhermitte Sign: Neck flexion results in a "shock sensation" (seen in multiple sclerosis and cervical spine problems)

List: Lateral tilt of the spine; usually associated with herniated disk and muscle spasm

Lordosis: Accentuated normal concavity of the lumbar spine, normal in pregnancy

Louvel Sign: Coughing or sneezing causes pain in the leg with DVT

Marcus Gunn Pupil: Dilation of pupils with swinging flashlight test. Results from unilateral optic nerve disease. Normal pupillary response is elicited when light is directed from the normal eye and a subnormal response when light is quickly directed from the normal eye into the abnormal eye. When light is directed into the abnormal eye, both pupils dilate rather than maintain the previous degree of miosis.

McBurney Point/Sign: Point located one third of the distance from the anterior superior iliac spine to the umbilicus on the right. (Tenderness at the site is associated with acute appendicitis)

McMurray Test: Palpable or audible click on the joint line produced by external rotation of the foot, suggesting medial meniscal injury

M bius Sign: Inability to maintain convergence, seen in thyrotoxicosis

Moro Reflex (Startle Reflex): Abduction of hips and arms with extension of arms when infant's head and upper body are suddenly dropped several inches while being held. Normal reflex in early infancy

Murphy Sign: Severe pain and inspiratory arrest with palpation of the right upper quadrant during deep inspiration (associated with cholecystitis)

Musset or de Musset Sign: Rhythmic nodding or movement of the head with each heart beat, caused by blood flow back into the heart secondary to aortic insufficiency

Obturator Sign: Hypogastric pain elicited by flexion and internal rotation of the thigh in cases of inflammation of the obturator internus (present with pelvic abscess and appendicitis)

Ortolani Test/Sign: Sign: hip click that suggests congenital hip dislocation. Test: with the infant supine, point the legs toward you and flex the legs to 90 degrees at the hips and knees

Osler Node: Tender, red, raised lesions on the hands or feet (seen with SBE)

Pancoast Syndrome: Carcinoma involving apex of lung, resulting in arm and/or shoulder pain from involvement of brachial plexus and Horner syndrome from involvement of the superior cervical ganglion

Pastia Lines: Linear striations of confluent petechiae in axillary folds and antecubital fossa, seen in scarlet fever

Phalen Test: Prolonged maximum flexion of wrists while opposing dorsum of each hand against each other. A positive test result is pain and tingling in the distribution of the median nerve (seen in carpal tunnel syndrome)

Psoas Sign (Iliopsoas Test): Flexion against resistance or extension of the right hip, producing pain; seen with inflammation of the psoas muscle (present with appendicitis)

Pulsus Alternans: Fluctuation of pulse pressure with every other beat (seen in aortic stenosis and CHF)

Queckenstedt Test: compression of the internal jugular vein during lumbar puncture to determine patency of the subarachnoid space; normal result is immediate increase in CSF pressure

Quincke Sign: Alternating blushing and blanching of the fingernail bed after light compression (seen in chronic aortic regurgitation)

Radovici Sign: Chin contractions caused by scratching of the palm; a frontal release sign

Raynaud Phenomenon/Disease: Pain and tingling in fingers after exposure to cold with characteristic color changes of white to blue and then often red. May be seen with scleroderma and SLE or be idiopathic (Raynaud disease)

Romberg Test: The patient stands with heels and toes together with arms outstretched palms facing up or down or arms at sides. The examiner lightly taps the patient, first with the patient's eyes open and then with the patient's eyes closed. A positive result is the patient's loss of balance. Loss of balance with the eyes open indicates cerebellar dysfunction. Normal balance with eyes open and loss of balance with eyes closed indicate loss of position sense. Used to test position sense and cerebellar function

Roth Spots: Oval retinal hemorrhages with a pale central area occurring in patients with bacterial endocarditis

Rovsing Sign: Pain in the RLQ with deep palpation of the LLQ (seen in acute appendicitis)

Schmorl Node: Degeneration of the intervertebral disk resulting in herniation into the adjacent vertebral body

Scoliosis: Lateral curvature of the spine

Sentinel Loop: A single dilated loop of small or large bowel, usually secondary to localized inflammation such as pancreatitis

Sister Mary Joseph Sign/Node: Metastatic cancer to umbilical lymph node

Stellwag Sign: Infrequent ocular blinking

Tinel Sign: Radiation of an electric shock sensation in the distal distribution of the median nerve elicited by percussion of the flexor surface of the wrist when fully extended (seen in carpal tunnel syndrome)

Traube Sign: Booming or pistol shot sounds heard over the femoral arteries in chronic aortic insufficiency

Trendelenburg Test: Patient shifts weight from one leg to the other while being observed from behind; a pelvic tilt to opposite side suggests hip disease and weakness of the gluteus medius muscle. A normal pelvis does not tilt.

Trousseau Sign: Carpal spasm produced by inflation of a BP cuff above the systolic pressure for 2 3 min, indicates hypocalcemia or migratory thrombophlebitis associated with cancer

Turner Sign: See Grey Turner sign

Virchow Node (Signal or Sentinel Node): A palpable, left supraclavicular lymph node; often first sign of a GI neoplasm, such as pancreatic or gastric carcinoma

von Graefe Sign: Lid lag associated with thyrotoxicosis

Weber Rinne Test: Weber test: place a 512- or 1024-Hz tuning fork on the middle of the patient's skull to determine if the sound lateralizes. Rinne test: hold the tuning fork against the patient's mastoid process (BC) with the opposite ear covered. The patient indicates when the sound is gone. Then hold the tuning fork next to the ear, and the patient indicates whether the sound is present and when the sound (AC) disappears. Normally AC is better than BC. With sensorineural hearing loss, the Weber test lateralizes to the less affected ear, and AC > BC; with conduction hearing loss, the Weber test lateralizes to the more affected ear, and BC > AC.

Whipple Triad: Hypoglycemia, CNS, and vasomotor symptoms (ie, diaphoresis, syncope); relief of symptoms with glucose (associated with insulinoma)

Example of a Written History and Physical Examination

(Adult Admitted to a Medical Service)

12/10/06 5:30 PM

Identification

Mr. Robert Jones is a 50-y-old man referred by Dr. Harry Doyle from Whitesburg, Kentucky. The informant is the patient, who seems reliable, and a photocopy of the ER records from Whitesburg Hospital accompanies the patient.

Chief Complaint

"Squeezing chest pain for 10 h, 4 d ago"

HPI

Mr. Jones awoke at 6 AM 3 d ago with squeezing substernal chest pain that felt "like a ton of bricks" sitting on his chest. The chest pain was a 9 on a 10-point scale and decreased in intensity after the trip to the Whitesburg emergency department. The pain radiated to the left side of the neck and left elbow and was associated with dyspnea and diaphoresis. The patient says he experienced no associated nausea. He says the pain seemed to get worse with any movement, and nothing seemed to alleviate it.

Mr. Jones presented to the Whitesburg ER 10 h after the onset of pain and was given 3 NTG tablets SL and 2 mg morphine sulfate. ECG revealed 3-mm ST depression in leads V₁ through V₄. He was admitted to the ICU at Whitesburg Hospital and had an uneventful course. CK increased to 850 U/L at 24 h, and troponin increased to 12.5 ng/mL. He has been taking aspirin 325 mg/d PO, isosorbide dinitrate 20 mg PO q6h, and metoprolol 100 mg PO q12h. He was transferred for possible cardiac catheterization.

Mr. Jones reports having experienced similar chest pain that was less intense and occurred intermittently over the last 3 mo. The pain was precipitated by exercise and relieved with rest. He sought no medical attention in the past. He reports no history of orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion, or pedal edema.

Mr. Jones has smoked two packs of cigarettes per day for 35 y, reports a 2-y history of HTN, for which he has been taking HCTZ 25 mg/d, and reports no history of hypercholesterolemia or diabetes. He says his BP usually runs 120 130/85 at home. The patient's father died of MI at age 54, and his brother underwent CABG surgery last year at age 48.

PMH

Medications. As above and ranitidine 300 mg PO qhs. Occasional ibuprofen 200 mg 2 3 tabs PO for back pain and acetaminophen 500 mg PO for HA

Vitamins. One-a-day

Herbals. None

Allergies. Penicillin, rash entire body at age 20 y

Surgical Procedures. Appendectomy age 20, Dr. Smith, Whitesburg

Hospitalization. See above.

Trauma. Roof fall in mine accident 10 y ago, injured back. Reports occasional pain, which is relieved with ibuprofen 200 mg 2 3 tabs at a time

Transfusions. None

Illnesses. Reports no asthma, emphysema, thyroid disease, kidney disease, peptic ulcer disease, cancer, bleeding disorders, tuberculosis, or hepatitis. Reports a several-year history of water brash/heartburn and has been on ranitidine for 1 y

Routine Health Maintenance. Last diphtheria/tetanus immunization 3 y ago Stools for guaiac were negative x 3. Refused sigmoidoscopy. Patient has been seen by Dr. Doyle every 3 4 mo for the last 2 y for HTN.

Family History

Psychosocial History:

Mr. Jones has been married for 25 y and has three children.

Mr. Jones and his family live in a house on 3 acres about 3 miles from Whitesburg. He worked in a coal mine until 10 y ago, when he was injured in a "roof fall." He is currently employed in a local chair factory. He graduated from high school. He is Baptist and attends church regularly. Hobbies include woodworking and gardening. He eats breakfast and supper every day and has a soft drink and crackers for lunch. He currently works 8 h/d Monday through Friday. He reports going to bed every day by 10:00 PM and awakens at 5:30 AM. He drinks one to two cups of coffee per day and reports drinking no alcohol. He says he does not use drugs but smokes as noted earlier. He reports he has never been exposed to environmental toxins. He says he has no financial problems but is concerned about how his illness will affect his income. He has "good" health insurance. He denies any other stressors in his life. His sources of support are his wife, minister, and a sister who lives near the patient.

ROS

Negative unless otherwise noted.

Eyes: Has worn reading glasses since 1995; reports blurred vision for 1 year; last eye appointment 2001. Claims no loss of vision, double vision, or history of cataracts.

Respiratory: Reports cough every morning and has produced one teaspoon of gray sputum for years. Denies hemoptysis or pleuritic chest pain. Last CXR before today was 3 years ago. All other ROS negative.

Physical Examination

General: Mr. Jones is a pleasant man lying comfortably supine in bed. He appears to be the stated age.

Vital Signs: Temp 98.6 F orally. Resp 16, HR 88 and regular, BP 110/70 mm Hg left arm supine

Skin: Tattoo left arm, otherwise no lesions

Node: 1 x 1 left axillary node, nontender and mobile. No other lymphadenopathy

HEENT

Head. Normocephalic, atraumatic, nontender, no lesions

Eyes. Visual acuity 20/40 left and right corrected. External structures normal, without lesions, PERRLA. EOM intact. Visual fields intact. Funduscopic examination discs sharp bilaterally, moderate arteriolar narrowing and A V nicking

Ears. Hearing intact to watch tick at 3 ft bilaterally. Tympanic membranes intact with good cone of light bilaterally

Nose. Symmetrical. No lesions. Sinuses nontender

Mouth. Several dental fillings, otherwise normal dentition. No lesions

Neck. Full ROM without tenderness. No masses or lymphadenopathy. Carotids +2/4 bilaterally, no bruits. Internal jugular vein visible 2 cm above the sternal angle, patient at 30 degrees

Chest: Symmetrical expansion. Fremitus by palpation bilaterally equal. Diaphragm moves 5.5 cm bilaterally by percussion. Lung fields clear to percussion. Breath sounds normal, except end-inspiratory crackles heard at both bases that do not clear with coughing.

Breast: Normal to inspection and palpation

Heart: No cardiac impulse visible. Apical impulse palpable at the sixth intercostal space 2 cm lateral to the midclavicular line. Normal S₁, physiologically split S₂. S₄ heard at apex. No murmurs, rub, or S₃

Abdomen: Flat, no scars. Bowel sounds present. No bruits. Liver 10 cm midclavicular line. No CVA tenderness. No hepatomegaly or splenomegaly by palpation. No tenderness or guarding. No inguinal lymphadenopathy

Genital: Normal circumcised man, both testes descended without masses or tenderness

Rectal: Normal sphincter tone. No external lesions. Prostate smooth without tenderness or nodules. No palpable masses. Stool present, stool for occult blood negative

Musculoskeletal: Lumbar spine decreased flexion to 75 degrees, extension to 5 degrees, decreased rotary and lateral movement. Otherwise full ROM of all joints, no erythema, tenderness, or swelling. No clubbing cyanosis or edema

Peripheral Vascular: Radial, ulnar, brachial, femoral, dorsalis pedis, and posterior tibial pulses +2/4 bilaterally. Popliteal pulses nonpalpable. No femoral bruits

Neurologic: Cranial nerves: I through XII intact. Motor: +5/5 upper and lower extremity, proximally and distally. Sensory: Intact to pinprick upper and lower extremities proximally and distally. Vibratory sense intact in great toes and thumbs bilaterally. Stereognosis intact. Reflexes: Biceps, triceps, brachioradialis, quadriceps, and ankles +2/4 bilaterally. Toes down going bilaterally. Cerebellum. Romberg sign absent. Intact finger-to-nose and heel-to-shin bilaterally; gait normal normal heel-and-heel, toe-and-toe, and heel-to-toe gaits. Rapid alternating movements intact upper and lower extremities bilaterally

Database

ECG. HR 80, NSR inverted T waves V₁ through V₅

CXR. Cardiomegaly, otherwise clear

UA. SG 1.020, protein trace otherwise negative

PT, PTT. 12.1, control 11.7, INR 1.1;28, control 27

Chemistry Profile. CK 250 U/L, otherwise normal

Troponin. 4.0 ng/mL

CBC. 6700 WBC; 49% HCT; Hbg 16 g/dL; 43 S, 2 B, 40 L, 5 M, 10 E

Problem List

Date Entered	Date of Onset	Problem	Active	Inactive	Date Inactive
12-10-06	9-06	1	Coronary artery disease
12-10-06	12-10-06	1a	Subendocardial
			MI anterior
12-10-06	2004	2	Hypertension
12-10-06	1990s	3	Bronchitis
12-10-06	2004	4	Heartburn/reflux esophagitis
12-10-06	1996	5	Back injury
12-10-06	12-10-06	6	Eosinophilia
12-10-06	2002	7	Blurred vision
12-10-06	1976	8		Appendicitis	1976

Assessment and Plan

Coronary Artery Disease

Mr. Jones presented with a classic history for MI. The CK and electrocardiogram support the diagnosis. The ST depression without evolving Q waves is consistent with a nontransmural MI. Mr. Jones is at risk of further MI because it was a nontransmural MI, and he needs further evaluation before discharge.

Continue aspirin 325 mg/d PO and metoprolol 100 mg q12h.
Change isosorbide to tid before discharge.
Monitor by telemetry unit for next 24 48 h.
Stress test by modified Bruce protocol before discharge.
Consider cardiac catheterization, especially if further pain occurs or with early positive result of stress test.
Continue cardiac rehabilitation.

Hypertension

In view of the patient's age, sex, and degree of HTN and the fact that there is no evidence of a secondary cause, the HTN is most likely primary in nature. It is important that BP be well controlled after this infarction. Mr. Jones' BP has been well controlled with HCTZ alone, and he is now also taking metoprolol.

Continue metoprolol and HCTZ.
Dietary consult before discharge to instruct patient on low-sodium as well as low-fat diet.
Continue discussion of other problems as shown earlier.

Chronic Cough with Sputum Production

Most likely chronic bronchitis. Consider bronchiogenic carcinoma; however, CXR is normal except for heart size. Encourage smoking cessation.

Signature: ______________________________

Title: ______________________________________