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					                         Contents
Part 1: The Art of Assessment and Clinical Decision Making             1
 Chapter 1: Assessment and Clinical Decision-Making: An Overview   2
    History 2
    Physical Examination 3
    Diagnostic Studies 4
    Diagnostic Statisties 4
    Clinical Decision-Making Resorces    6
    The Diagnostic Process 7
    Summary 9
    Suggested Readings 10

Part 2: Advanced Assessment and Differential Diagnosis by
        Body Regions and Systems 11
 Chapter 2: Skin    12
    History 12
      General Integumentary History 12
      Past Medical History 13
      Family History 13
      Habits 13
    Physical Examination 13
      Order of the Exam 13
      Assessing Skin Lesions 16
    Differential Diagnosis of Common Chief Complaints   17
      Vesicles (Blisters) 17
      Bullae (Large Blisters) 20
      Pustules 20
      Keratotic Lesions 21
      Raised, Skin-Colored Lesions 22
      White Lesions 24
      Brown Lesions 25
      Inflammatory or Red Lesions 26
      Eczematous Lesions with Excoriations 30
    Suggested Readings 31
 Chapter 3: Head, Face, and Neck        32
    History 32
      General History 32
      Past Medical History 33
      Family History 33
      Habits 33
    Physical Examination 33

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        Differential Diagnosis of Chief Complaints   33
          Head Pain and Headache 33
          Jaw Pain and Facial Pain 35
          Facial Swelling 39
          Facial Numbness 41
          Scalp and Face Pruritus 42
          Neck Fullness/Mass or Pain 43
          Difficulty Swallowing 47
        Suggested Readings 49
      Chapter 4: The Eye      51
        History 51
          General Eye History 51
          Past Medical History 51
          Family History 52
          Habits 52
        Physical Examination 53
          Order of the Examination 53
          Visual Acuity 53
          Peripheral Vision 53
          Alignment 53
          Accessory Structures 53
          External Eye Structures 53
          Pupils 53
          Anterior Chamber and Lens 53
          Cranial Nerves 53
          Funduscopic Examination 56
        Differential Diagnosis of Chief Complaints   57
          Visual Disturbances 57
          Reddened Eye 64
          Eye Pain 69
          Eye Discharge 71
          Ptosis 72
          Double Vision 74
        Suggested Readings 75
      Chapter 5: Ear, Nose, Mouth, and Throat        77
        History 77
          General History 77
          History of the Present Illness   77
          Past Medical History 79



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    Family History 80
    Habits 80
    Review of Systems 80
  Physical Examination 80
    Order of the Examination 80
  Differential Diagnosis of Chief Complaints: Ear 84
    Ear Pain (Otalgia) 84
    Ear Discharge (Otorrhea) 88
    Decreased Hearing or Hearing Loss 90
    Ringing (Tinnitus) 94
    Ear Fullness 95
  Differential Diagnosis of Chief Complaints: Nose 96
    Bleeding (Epistaxis) 96
    Congestion and/or Drainage 100
    Loss of Smell 102
  Differential Diagnosis of Chief Complaints: Mouth 102
    Mouth Sores (Painful and Painless) 102
    Mouth Pain Without Obvious Lesions 108
  Differential Diagnosis of Chief Complaints: Throat 109
    Sore Throat or Throat Pain 109
    Hoarseness 114
  Suggested Readings 116
Chapter 6: Cardiac and Peripheral Vascular Systems    117
  Cardiac System 117
  Anatomy and Physiology 117
    Heart Sounds 117
    The Cardiac Cycle 119
  History 120
    General History 120
    Past Medical History 121
    Family History 121
    Habits 121
  Physical Examination 121
    General Assessment 121
    Inspection 122
    Auscultation 122
    Palpation 123
    Percussion 123
  Cardiovascular Laboratory Tests   123



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        Differential Diagnosis of Chief Complaints 124
          Palpitations or Arrhythmia 124
          Irregular Pulse 126
          Chest Pain 128
          Patient History of Heart Murmur 132
          Elevated Blood Pressure 138
          History of Elevated Lipids 140
          Difficulty Breathing and Shortness of Breath 142
          Acute and Subacute Bacterial Endocarditis 145
        Peripheral Vascular System 145
        Differential Diagnosis of Chief Complaints 146
          Peripheral Edema 146
          Leg Pain 148
        References 150
      Chapter 7: Respiratory System     152
        History 152
          Symptom Analysis 152
          Past Medical and Family History 153
          Habits 153
        Physical Examination 154
          Inspection 154
          Palpation 154
          Percussion 155
          Auscultation 155
          Diagnostic Studies 156
          Imaging Studies 157
        Differential Diagnosis of Chief Complaints   157
          Cough 157
          Shortness of Breath and Dyspnea 162
          Wheezing and Chest Tightness 164
          Hemoptysis 165
          Pleuritic Pain 165
        References 167
        Suggested Readings 167
      Chapter 8: Breasts   168
        History 168
          General History: Symptoms Analysis and Review of Systems   169
          Past Medical History 169
          Family History 169
          Habits 169


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  Physical Examination 169
    Order of the Examination 170
    Special Considerations 171
  Differential Diagnosis of Chief Complaints   172
    Breast Mass 172
    Breast Pain 175
    Breast Discharge 178
    Male Breast Enlargement or Mass 180
  Reference 182
  Suggested Readings 182
Chapter 9: Abdomen      183
  History 183
    General History 183
    Past Medical History 184
    Family History 184
    Habits 184
  Physical Examination 184
    Order of the Examination 184
    Special Maneuvers 187
  Differential Diagnosis of Chief Complaints   189
    Abdominal Pain 189
    Nausea and Vomiting 207
    Diarrhea 212
    Constipation 217
    Jaundice 221
    Gastrointestinal Bleeding 225
  References 228
  Suggested Readings 228
Chapter 10: Genitourinary System        229
  History 230
    General History 230
    Past Medical and Surgical History   230
    Family History 230
    Sexual History 231
  Physical Examination 231
    General History 231
    Patterns of GU Pain 231
  Diagnostic Studies 232
    Laboratory Evaluation 232
    Radiologic Evaluation 234


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         Differential Diagnosis of Chief Complaints   237
           General Complaints 237
           Lower Urinary Tract Symptoms 248
           Urinary Incontinence 256
         References 258
         Suggested Readings 259
      Chapter 11: Male Reproductive System        260
        History 260
          General History 260
          Past Medical History 260
          Family History 261
          Sexual History 261
          Habits 261
        Physical Examination 262
          Order of the Examination 262
          Special Maneuvers 262
        Differential Diagnosis of Chief Complaints 264
          General Complaints 264
          Erectile Function Complaints 277
          Complaints Related to Male Fertility and Sexual Function   284
        References 288
      Chapter 12: Female Reproductive System 289
        Anatomy and Physiology
          Reproductive Hormones 289
        History 291
          General History 291
          Past Medical History 293
          Habits 293
        Physical Examination 294
          Order of the Examination 294
        Differential Diagnosis of Chief Complaints 295
          Mass and/or Swelling at the Introitus 295
          Vaginal Discharge 299
          Labial Lesions 304
          Abnormal Pap Smear 307
          Dysfunctional Uterine Bleeding 308
          Amenorrhea 312
          Dysmenorrhea 315
          Ovarian Cancer 316
          Sexual Dysfunction 318


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   Dyspareunia 319
     Infertility 320
   References 320
Chapter 13: Musculoskeletal System 321
  Anatomy and Physiology 321
    Bones and Joints 322
  Assessment of Musculoskeletal Complaints 322
  History 322
    General Musculoskeletal History 322
    Past Medical History 323
    Family History 323
    Habits 323
  Physical Examination 324
    Order of the Examination 324
    Range of Motion 325
    Ligamentous Tests 325
    Muscle Strength and Tone 325
    Special Maneuvers 326
  Diagnostic Studies 326
  Differential Diagnosis of Chief Complaints 326
    Joint Pain 327
    Polyarthralgia 327
    Neck Pain 331
    Low Back Pain 335
    Isolated or Limited Joint Pain 339
    Shoulder Pain 339
    Elbow Pain 342
    Wrist and Hand Pain 343
    Hip Pain 344
    Knee Pain 346
    Ankle and Foot Pain 350
    Myalgia 351
  Conclusion 352
  Suggested Readings 353
Chapter 14: Neurological System 354
  History 354
    Chief Complaint and the History of Present Illness   354
    General History and the Review of Systems 354
    Medical and Surgical History 355
    General Neurologic History 355


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            Social History 355
            Family History 355
          Physical Examination 355
            General Appearance and Affect 356
            Mental Status 356
            Cranial Nerve Examination 357
            Motor Function 357
            Reflexes 358
            Coordination 358
            Cerebrovascular 358
            Fundoscopic Examination 359
            Sensory Examination 359
          Differential Diagnosis of Chief Complaints 359
            Headache or Cephalalgia 359
            Altered Mental Status 369
            Dizziness and Vertigo 373
          References 377
          Suggested Readings 378
        Chapter 15: Nonspecific Complaints 379
          History and Physical Examination 379
          Differential Diagnosis of Chief Complaints 379
            Fatigue 379
            Weakness 386
            Fever of Unknown Origin 389
            Unexplained Weight Loss 391
          Suggested Readings 394
        Chapter 16: Psychiatric Mental Health 395
          Comprehensive Psychiatric Evaluation 396
            Problem Identification and Chief Complaint 396
            History of Present Illness 396
            Pertinent Past Psychiatric History 396
            Pertinent Social History 396
            Pertinent Family History 397
            Medical History and the Review of Symptoms 397
            Mental Status Examination 397
            Assessing for Potential Medical Mimics 398
          Differential Diagnosis oF Chief Complaints 398
            Anxiety 398
            Mood Disorders 402



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       Substance-Related Disorders 408
       Eating Disorders 411
       Thought Disorders 414
    Issues Related to Older Adults 418
    References 419
    Suggested Readings 419

PART 3: Assessments and Differential Diagnosis with Special
        Patient Populations 421
 Chapter 17: Pediatric Patients 422
    Communicating with Infants and Children During the Pediatric Assessment   422
      Infants 422
      Toddlers 422
      Preschoolers 423
      School-Age Children 423
      Adolescents 423
    Pediatric History and Physical Examination 423
      Head 424
      Eyes 424
      Ears 425
      Nose and Sinuses 425
      Mouth and Throat 426
      Lungs 426
      Heart 427
      Breasts 427
      Abdomen 429
      Genitourinary System 430
      Musculoskeletal System 431
      Neurological System 434
      Skin 434
    Growth and Development 436
      Physical Growth 436
      Development by Age 437
      Hearing/Speech 442
      Vision 443
      Nutrition 444
      Anticipatory Guidance and Safety 446
      Teething and Tooth Eruption 446
    Suggested Readings 449




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     Chapter 18: Pregnant Patients 451
       History 451
       Physical Examination 452
       Laboratory Studies 454
       Prenatal Education 454
       Common Chief Complaints and Discomforts of Pregnancy 456
         GI Complaints 456
         Abdominal Pain 458
         Musculoskeletal Complaints 458
         Respiratory Complaints 460
         Fatigue 462
         Genitourinary Complaints 462
         Circulatory Complaints 463
       Pregnancy Complications 464
         Anemia 464
         Gestational Diabetes 466
         Hypertension 468
         Vaginal Bleeding 469
         Vaginal Infections 470
         Urinary Tract Infections 471
         Size Not Equal to Dates 471
         Preterm Labor 473
       Summary 474
       References 474
       Suggested Readings 475
     Chapter 19: Older Patients 477
       The Demographics of Aging 478
       The Approach to the Assessment of Older Individuals 479
       The Physiology of Aging 480
       Functional Assessment 483
         Measures of Function 483
         Measures of Cognitive Function 483
       The Atypical Presentation of Common Conditions 489
         Case Analysis 490
       Geriatric Syndromes 492
       The Assessment of Driving Safety 494
         General History 494
         Focused History 494
         Habits 495



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     Physical Examination 495
     Resources 496
   Head, Eyes, Ears, Nose, and Mouth   497
   Neuromuscular System 498
   Nutritional Assessment 500
   Advance Care Planning 503
   Conclusion 504
   References 504
Index 506




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