Evidence-Based Physical Diagnosis

Evidence-based Physical Diagnosis
Copyright
Dedication
Preface to the Fourth Edition
Introduction to the First Edition
Part 1: Introduction
	Chapter 1: What Is Evidence-based Physical Diagnosis?
Part 2: Understanding the Evidence
	Chapter 2: Diagnostic Accuracy of Physical Findings
		I. Introduction
		II. Pre-test Probability
		III. Sensitivity and Specificity
			A. Definitions
			B. Using Sensitivity and Specificity to Determine Probability of Disease
		IV. Likelihood Ratios
			A. Definition
			B. Using Likelihood Ratios to Determine Probability
				1. Using Graphs
					a. Parts of the Graph
					b. Using the Graph to Determine Probabilit
				2. Approximating Probability
				3. Calculating Probability
			C. Advantages of Likelihood Ratios
				1. Simplicity
				2. Accuracy
				3. Levels of Findings
				4. Combining Findings
					a. Independence of Findings
					b. How to Combine Findings
		References
	Chapter 3: Using the Tables in This Book
		I. Introduction
		II. Frequency of Findings Tables
			A. Definition
			B. Parts of the Table
				1. Finding
				2. Frequency
				3. Footnotes
			C. Interpretation
		III. Diagnostic Accuracy Tables (ebm Boxes)
			A. Definition
			B. Parts of the EBM Box
				1. Finding
				2. Sensitivity and Specificity
				3. Likelihood Ratios
				4. Footnote
			C. Interpretation of EBM Boxes
		IV. Criteria for Selecting Studies Used in Diagnostic Accuracy Tables
			A. Patients Were Symptomatic
			B. Definition of Physical Sign
			C. Independent Comparison to a Diagnostic Standard
			D. 2 × 2 Table Could Be Constructed
		V. Summarizing Likelihood Ratios
		References
	Chapter 4: Using the Evidence-based Medicine Calculator (expert Consult)
		I. The Evidence-based Medicine Calculator
		II. Using the Calculator
			A. Blank Calculator
			B. Calculating Probability for Specific Conditions
	Chapter 5: Reliability of Physical Findings
		Appendix: Calculation of the κ-statistic
		References
Part 3: General Appearance of the Patient
	Chapter 6: Mental Status Examination
		I. Introduction
		II. Clock-drawing Test
			A. Technique and Scoring
			B. Clinical Significance
		III. Mini-cog Test
			A. Technique and Scoring
			B. Clinical Significance
		IV. Mini-mental Status Examination
			A. Introduction
			B. Clinical Significance
		V. Diagnosis of Delirium (Confusion Assessment Method)
			A. Scoring
			B. Clinical Significance
		References
	Chapter 7: Stance and Gait
		I. Introduction
		II. Etiology of Gait Disorders
		III. Types of Gait Disorders and Their Significance
			A. Painful Gait (Antalgic Gait)
				1. Short Contralateral Step
				2. Other Characteristic Features
					a. Foot Pain
					b. Knee Pain
					b. Hip Pain (Coxalgic Gait)
			B. Immobile Joints
			C. Weakness of Specific Muscles
				1. Trendelenburg Gait and Sign (Abnormal Gluteus Medius and Minimus Gait)
					a. Definition of Trendelenburg Gait (or Trendelenburg’s Symptom; Friedrich Trendelenburg 1844–1924)
					b. Etiology of Trendelenburg Gait
					c. Trendelenburg Sign
					d. Clinical Significance
				2. Gluteus Maximus Gait
				3. Weak Quadriceps Gait
			D. Spasticity
				1. Hemiplegic Gait
				2. Diplegic Gait
			E. Rigidity
				1. The Parkinsonian Gait (Fig. 7.5)
				2. Differential Diagnosis
				3. Clinical Significance
			F. Ataxia
				1. Sensory Ataxia
				2. Cerebellar Ataxia
				3. Romberg Sign
					a. Introduction
					b. Definition of a Positive Romberg Sign
			G. Frontal Gait Disorder
				1. Definition
				2. Clinical Significance
		IV. Evaluation of Gait Disorders
			A. Observational Gait Analysis
			B. Predicting Falls
				1. The Findings
					a. Stops Walking When Talking
					b. Timed Up-and-go Test
				2. Clinical Significance
		V. Canes
			A. Length of Cane
			B. Contralateral Versus Ipsilateral Use of Cane
		References
	Chapter 8: Jaundice
		I. Introduction
		II. The Findings
			A. Jaundice
			B. Associated Findings
				1. Hepatocellular Jaundice
					a. Spider Telangiectasia (Spider Angiomas)
					b. Palmar Erythema
					c. Gynecomastia and Diminished Body Hair
					d. Dilated Abdominal Veins
					e. Palpable Spleen
					f. Asterixis
					g. Fetor Hepaticus
				2. Obstructive Jaundice: Palpable Gallbladder (Courvoisier Sign)
		III. Clinical Significance
			A. Detection of Jaundice
			B. Hepatocellular Versus Obstructive Jaundice
			C. Diagnosis of Cirrhosis
			D. Detecting Large Gastroesophageal Varices in Patients with Cirrhosis
			E. Detecting Hepatopulmonary Syndrome
			F. Detecting Portopulmonary Hypertension
		References
	Chapter 9: Cyanosis
		I. Definitions
		II. Pathogenesis
			A. The Blue Color
			B. Peripheral Cyanosis
		III. The Finding
			A. Central Cyanosis
			B. Peripheral Cyanosis
			C. Pseudocyanosis
			D. Cyanosis and Oximetry
		IV. Clinical Significance
			A. Central Cyanosis
			B. Peripheral Cyanosis
			C. Pseudocyanosis
		References
	Chapter 10: Anemia
		I. Introduction
		II. The Findings
		III. Clinical Significance
		References
	Chapter 11: Hypovolemia
		I. Introduction
		II. The Findings and Their Pathogenesis
		III. Clinical Significance
		References
	Chapter 12: Protein-energy Malnutrition and Weight Loss
		Protein-energy Malnutrition
			I. Introduction
			II. The Findings
				A. Arm Muscle Circumference
				B. Grip Strength
			III. Clinical Significance
		Weight Loss
			I. Introduction
			II. Clinical Significance
		References
	Chapter 13: Obesity
		I. Introduction
		II. The Findings and Their Significance
			A. Body Mass Index
				1. The Finding
				2. Clinical Significance
			B. Skinfold Thickness
			C. Waist-to-hip Ratio
				1. The Finding
				2. Clinical Significance
				3. Pathogenesis
			D. Waist Circumference
			E. Sagittal Diameter
		References
	Chapter 14: Cushing Syndrome
		I. Introduction
		II. The Findings and Their Pathogenesis
			A. Body Habitus
			B. Hypertension
			C. Skin Findings
			D. Proximal Weakness
			E. Depression
			F. Pseudo-cushing Syndrome
		III. Clinical Significance
			A. Diagnostic Accuracy of Findings
			B. Etiology of Cushing Syndrome and Bedside Findings
		References
Part 4: Vital Signs
	Chapter 15: Pulse Rate and Contour
		Pulse Rate
			I. Introduction
			II. Technique
			III. The Finding
			IV. Clinical Significance
		Abnormalities of Pulse Contour
			I. Pulsus Alternans
				A. The Finding
				B. Technique
				C. Clinical Significance
				D. Pathogenesis
			II. Pulsus Bisferiens
				A. The Finding
				B. Technique
				C. Clinical Significance
				D. Pathogenesis
			III. Pulsus Paradoxus
				A. The Finding
				B. Technique
				C. Clinical Significance
					1. Cardiac Tamponade
					2. Cardiac Tamponade Without Pulsus Paradoxus
					3. Asthma
					4. Pulsus Paradoxus in Other Conditions
					5. Reversed Pulsus Paradoxus
				D. Pathogenesis
					1. Cardiac Tamponade
					2. Asthma
			IV. Pulsus Parvus ET Tardus
				A. The Finding and Technique
				B. Clinical Significance
				C. Pathogenesis
			V. Dicrotic Pulse
				A. The Finding and Technique
				B. Clinical Significance
				C. Pathogenesis
			VI. Hyperkinetic Pulse
				A. The Finding
				B. Clinical Significance
			VII. Pulses and Hypovolemic Shock
		References
	Chapter 16: Abnormalities of Pulse Rhythm
		I. Introduction
		II. Technique
		III. The Findings and Their Clinical Significance
			A. The Pause
				1. Terminology
				2. Basic Mechanism of the Pause
					a. Premature Beat
					b. Heart Block
				3. Bigeminal and Trigeminal Rhythms, and Grouped Beating
				4. Atrial Versus Ventricular Premature Contractions
					a. Compensatory Pause
					b. Cannon a Waves
			B. Regular Bradycardia
				1. Sinus Bradycardia
				2. Complete Heart Block
					a. Changing Intensity of the First Heart Sound
					b. Intermittent Appearance of Cannon a Waves in the Venous Pulse
					c. Other Evidence of Atrioventricular Dissociation
				3. Halved Pulse
			C. Regular Tachycardia
				1. Vagal Maneuvers
					a. Technique
					b. Response of Regular Tachycardias to Vagal Maneuvers
				2. Atrioventricular Dissociation
				3. Flutter Waves in the Venous Pulse
				4. Sensation of Pounding in the Neck
			D. Irregular Rhythm That Varies with Respiration
			E. Irregularly Irregular Rhythm (Chaotic Rhythm)
		References
	Chapter 17: Blood Pressure
		I. Introduction
		II. Technique
			A. Auscultatory Versus Oscillometric Methods
			B. Recommended Technique
			C. Korotkoff Sounds (Auscultatory Method)
				1. Definition of Systolic and Diastolic Blood Pressure
				2. Pathogenesis
			D. Measurement Using Palpation
			E. Postural Vital Signs
			F. Common Errors
				1. Wrong Cuff Size
				2. Auscultatory Gap
				3. Inappropriate Level of the Arm
				4. Terminal Digit Preference (Auscultatory Method)
			G. Other Variables
		III. The Findings and Their Clinical Significance
			A. Hypertension
				1. Essential Hypertension
				2. Pseudohypertension and Osler Sign
			B. Hypotension
			C. Differences in Pressure Between the Arms
				1. Subclavian Steal Syndrome
				2. Aortic Dissection
			D. Differences in Pressure Between Arms and Legs
				1. Chronic Ischemia of the Lower Extremities
				2. Coarctation of the Aorta
			E. Abnormal Pulse Contour
			F. Abnormal Pulse Pressure
				1. Abnormally Small Pulse Pressure
				2. Abnormally Large Pulse Pressure
			G. Orthostatic Hypotension
				1. Postural Vital Signs in Healthy Persons
				2. Vital Signs and Hypovolemia
					a. Postural Change in Pulse
					b. Postural Change in Blood Pressure
					c. Supine Pulse and Supine Blood Pressure
			H. Blood Pressure and Impaired Consciousness
			I. Capillary Fragility Test (Rumpel-Leede Test)
		References
	Chapter 18: Temperature
		I. Introduction
		II. Technique
			A. Site of Measurement
			B. Variables Affecting the Temperature Measurement
				1. Eating and Smoking
				2. Tachypnea
				3. Cerumen
				4. Hemiparesis
				5. Mucositis
		III. The Finding
			A. Normal Temperature and Fever
			B. Fever Patterns
			C. Associated Findings
				1. Focal Findings
				2. Relative Bradycardia
				3. Anhidrosis
				4. Muscle Rigidity
		IV. Clinical Significance
			A. Detection of Fever
			B. Predictors of Bacteremia in Febrile Patients
			C. Extreme Pyrexia and Hypothermia
			D. Fever Patterns
			E. Relative Bradycardia
			F. Fever of Unknown Origin
		References
	Chapter 19: Respiratory Rate and Abnormal Breathing Patterns
		Respiratory Rate
			I. Introduction
			II. Technique
			III. Finding
				A. The Normal Respiratory Rate
				B. Tachypnea
				C. Bradypnea
			IV. Clinical Significance
				A. Tachypnea
				B. Tachypnea and Oxygen Saturation
				C. Bradypnea
		Abnormal Breathing Patterns
			I. Cheyne-Stokes Breathing (Peroidic Breathing)
				A. Introduction
				B. The Finding
					1. The Breathing Pattern
					2. Associated Bedside Observations
				C. Clinical Significance
					1. Associated Conditions
					2. Prognostic Importance
				D. Pathogenesis
					1. Enhanced Sensitivity to Carbon Dioxide
					2. Circulatory Delay Between Lungs and Arteries
			II. Kussmaul Respirations
			III. Grunting Respirations
				A. Definition
				B. Pathogenesis
			IV. Abnormal Abdominal Movements
				A. Normal Abdominal Movements
				B. Abnormal Abdominal Movements
					1. Asynchronous Breathing
						a. Findings
						b. Clinical Significance
						c. Pathogenesis
					2. Respiratory Alternans
					3. Paradoxical Abdominal Movements
						a. Finding
						b. Clinical Significance
						c. Pathogenesis
			V. Orthopnea, Trepopnea, and Platypnea
				A. Orthopnea
					1. Finding
					2. Clinical Significance
					3. Pathogenesis
				B. Trepopnea
					1. Finding
					2. Clinical Significance
						a. Unilateral Parenchymal Lung Disease
						b. Congestive Heart Failure From Dilated Cardiomyopathy
						c. Mediastinal or Endobronchial Tumor
						d. Other Causes
				C. Platypnea
					1. Finding
					2. Clinical Significance
						a. Right-to-left Shunting of Blood Through a Patent Foramen Ovale or Atrial Septal Defect
						b. Right-to-left Shunting of Blood Through Intrapulmonary Shunts
		References
	Chapter 20: Pulse Oximetry
		I. Introduction
		II. The Finding
		III. Clinical Significance
			A. Advantages of Pulse Oximetry
			B. Limitations of Pulse Oximetry
				1. Dyshemoglobinemias
				2. Dyes
				3. Low Perfusion Pressure
				4. Exaggerated Venous Pulsations
				5. Ambient Light
		References
Part 5: Head and Neck
	Chapter 21: The Pupils
		Normal Pupil
			I. Introduction
			II. Size
			III. Hippus
			IV. Simple Anisocoria
			V. Normal Light Reflex
				A. Anatomy
				B. Clinical Significance
			VI. Near Synkinesis Reaction
		Abnormal Pupils
			I. Relative Afferent Pupillary Defect (Marcus Gunn Pupil)
				A. Introduction
				B. The Finding
				C. Clinical Significance
					1. Optic Nerve Disease
					2. Retinal Disease
					3. Cataracts Do Not Cause the Relative Afferent Pupillary Defect
			II. Argyll Robertson Pupils
				A. The Finding
				B. Clinical Significance
					1. Associated Disorders
					2. Differential Diagnosis of Light-near Dissociation
					3. Near-light Dissociation
			III. Oval Pupil
				A. Evolving Third Nerve Palsy From Brain Herniation
				B. Adie Tonic Pupil (See Later)
				C. Previous Surgery or Trauma to the Iris
			IV. Anisocoria
				A. Definition
				B. Technique
				C. Abnormal Pupillary Constrictor Muscle
					1. Full Third Nerve Palsy: Associated Ptosis and Paralysis of Ocular Movements
						a. Ipsilateral Brain Herniation (Hutchinson Pupil)
						b. Posterior Communicating Artery Aneurysm
					2. The Tonic Pupil
						a. the Finding
						b. Pathogenesis
						c. Clinical Significance
					3. Disorders of the Iris
						a. Pharmacologic Blockade of the Pupil with Topical Anticholinergic Drugs
					4. The Poorly Reactive Pupil—response to Pilocarpine
				D. Abnormal Pupillary Dilator
					1. Definition
					2. Horner Syndrome Versus Simple Anisocoria
					3. Clinical Significance of Horner Syndrome
						a. Etiology
							(1). Associated Findings
							(2). Facial Sweating
							(3). Distinguishing Third Nerve Lesions From First and Second Nerve Lesions: The Eyedrop Tests
				E. Intraocular Inflammation
			V. Diabetes and the Pupil
			VI. Pinpoint Pupils and Altered Mental Status
		References
	Chapter 22: Diabetic Retinopathy
		I. Introduction
		II. The Findings
			A. Nonproliferative Changes (Fig. 22.1)
			B. Proliferative Retinopathy
			C. Macular Edema
		III. Clinical Significance
			A. Visual Acuity and Diabetic Retinopathy
			B. Diagnostic Accuracy of Ophthalmoscopy
			C. Screening Recommendations
		References
	Chapter 23: The Red Eye
		I. Introduction
		II. The Findings
			A. Distinguishing Serious From Benign Disease
				1. Visual Acuity
				2. Pupillary Abnormalities
				3. Pupil Constriction Tests
					a. Direct Photophobia Test
					b. Indirect (Consensual) Photophobia Test
					c. Finger-to-nose Convergence Test
			B. Distinguishing Bacterial Conjunctivitis From Nonbacterial Causes
				1. Normal Conjunctival Anatomy
				2. Papillary Conjunctivitis Versus Follicular conjunctivitis
		III. Clinical Significance
			A. Distinguishing Serious From Benign Disease
			B. Distinguishing Bacterial Conjunctivitis From Nonbacterial Causes
				1. Individual Findings
				2. Combined Findings
		References
	Chapter 24: Hearing
		I. Introduction
		II. Technique
			A. Whispered Voice Test
			B. Finger Rub Test
			C. Ticking Watch Test
			D. Tuning Fork Tests
				1. Introduction
				2. The Frequency of the Tuning Fork
				3. Method of Striking the Fork
				4. Weber Test
				5. Rinne Test
		III. Clinical Significance
			A. Whispered Voice Test
			B. Finger Rub Test
			C. Ticking Watch Test
			D. Tuning Fork Tests
		References
	Chapter 25: Thyroid and Its Disorders
		Goiter
			I. Introduction
			II. Technique
				A. Normal Thyroid
				B. Examination for Goiter
					1. Inspection
					2. Palpation
					3. Observing the Patient Swallow
			III. The Findings
				A. Cervical Goiter
				B. Substernal and Retroclavicular Goiters
				C. Thyroglossal Cyst
				D. Pseudogoiter
				E. The Delphian Node
			IV. Clinical Significance
				A. Detecting Goiter
				B. Etiology of Goiter
		Thyroid Nodules
			I. Introduction
			II. Occult Nodules
			III. Clinical Significance
		Hypothyroidism (Myxedema)
			I. Introduction
			II. Findings and Their Pathogenesis
				A. Skin and Soft Tissue
				B. The Achilles Reflex
				C. Hypothyroid Speech
				D. Obesity
			III. Clinical Significance
		Hyperthyroidism
			I. Introduction
			II. Findings and Their Pathogenesis
				A. The Thyroid
				B. Eye Findings
					1. Lid Lag
					2. Lid Retraction
					3. Graves Ophthalmopathy
				C. Cardiovascular Findings
				D. Skin Findings
				E. Neuromuscular Findings
			III. Clinical Significance
		References
	Chapter 26: Meninges
		I. The Findings
			A. Neck Stiffness
			B. Kernig Sign
			C. Brudzinski Sign
		II. Pathogenesis of Meningeal Signs
		III. Clinical Significance
			A. Acute Bacterial Meningitis
			B. Subarachnoid Hemorrhage and Intracerebral Hemorrhage
		References
	Chapter 27: Peripheral Lymphadenopathy
		I. Introduction
		II. Anatomy and Pathogenesis
			A. Introduction
			B. Regional Lymph Node Groups
				1. Cervical Nodes
				2. Supraclavicular Nodes
				3. Epitrochlear Nodes
				4. Axillary Nodes
				5. Inguinal Nodes
		III. The Finding
			A. Describing Adenopathy
			B. Generalized Lymphadenopathy
			C. “Glandular” Syndromes
		IV. Clinical Significance
			A. Definition of Disease
			B. Extranodal Mimics of Lymph Nodes
			C. Individual Findings
			D. Combined Findings
			E. Lymph Node Syndromes
				1. Supraclavicular Adenopathy
				2. Epitrochlear Adenopathy
				3. Identifying Human Immunodeficiency Virus Infection in Developing Nations
				4. Fever of Unknown Origin
				5. Staging Patients with Known Cancer
				6. Ulceroglandular and Oculoglandular Syndromes
		References
Part 6: The Lungs
	Chapter 28: Inspection of the Chest
		I. Clubbing (Acropachy, Hippocratic Fingers)
			A. Introduction
			B. The Finding
				1. Interphalangeal Depth Ratio
				2. Hyponychial Angle
				3. Schamroth Sign
				4. Other Definitions
			C. Clinical Significance
				1. Etiology
				2. Relationship of Clubbing to Hypertrophic Osteoarthropathy
				3. Clubbing and Cystic Fibrosis
				4. Clubbing and Endocarditis
				5. Clubbing and Hepatopulmonary Syndrome
			D. Pathogenesis
		II. Barrel Chest
			A. The Finding
			B. Clinical Significance
		III. Pursed Lip Breathing
			A. The Finding
			B. Clinical Significance
		IV. Accessory Muscle Use
			A. The Finding
			B. Pathogenesis
			C. Clinical Significance
		V. Intensity of Breathing Sounds (Inspiratory White Noise; Noisy Breathing)
			A. The Finding
			B. Pathogenesis
			C. Clinical Significance
		References
	Chapter 29: Palpation and Percussion of the Chest
		Palpation
			I. Introduction
			II. Tactile Fremitus
				A. The Finding
				B. Technique
				C. Finding
			III. Clinical Significance
				A. Chest Expansion
				B. Tactile Fremitus
				C. Chest Wall Tenderness
		Percussion
			I. Introduction
			II. Technique
				A. Direct Versus Indirect Method
				B. Types of Percussion
					1. Comparative Percussion
					2. Topographic Percussion
					3. Auscultatory Percussion
				C. Percussion Blow
					1. Force
					2. Rapid Withdrawal of Plexor
			III. The Finding
				A. Percussion Sounds
				B. Sense of Resistance
				C. Glossary of Additional Percussion Terms
					1. Skodaic Resonance
					2. Grocco Triangle
					3. Metallic Resonance (Amphoric Resonance; Coin Test)
					4. Krönig Isthmus
					5. Cracked-pot Resonance
			IV. Pathogenesis
				A. Topographic Percussion Versus Cage Resonance Theory
					1. Analysis of Sound Recordings
					2. Condition and State of the Body Wall
					3. Strength of the Percussion Blow
				B. Auscultatory Percussion
			V. Clinical Significance
				A. Comparative Percussion
				B. Topographic Percussion of the Diaphragm
				C. Auscultatory Percussion
		References
	Chapter 30: Auscultation of the Lungs
		I. Breath Sounds
			A. Finding
				1. Vesicular Versus Bronchial Breath Sounds
				2. Breath Sound Score
			B. Pathogenesis
				1. Vesicular Sounds
					A. Origin
					B. Intensity
				2. Bronchial Sounds
			C. Clinical Significance
				1. Breath Sound Intensity
				2. Asymmetric Breath Sounds After Intubation
				3. Bronchial Breath Sounds
		II. Vocal Resonance
			A. The Finding
				1. Bronchophony
				2. Pectoriloquy
				3. Egophony
			B. Pathogenesis
			C. Clinical Significance
		III. Adventitious Sounds
			A. Introduction
			B. The Finding
				1. Crackles
				2. Wheezes and Rhonchi
				3. Stridor
				4. Pleural Rub
				5. Inspiratory Squawk
			C. Pathogenesis
				1. Crackles
				2. Wheezes
			D. Clinical Significance
				1. Crackles
					a. Normal Persons
					b. Crackles and Disease
						(1). Presence of Crackles
						(2). Characteristics of Crackles
				2. Wheezes
					a. Presence of Wheezes
					b. Characteristics of Wheezing
				3. Stridor
				4. Pleural Rub
		References
	Chapter 31: Ancillary Tests
		I. Forced Expiratory Time
			A. Technique
			B. Pathogenesis
			C. Clinical Significance
		II. Blow-out-the-match Test
			A. Technique
			B. Clinical Significance
		References
Part 7: Selected Pulmonary Disorders
	Chapter 32: Pneumonia
		I. Introduction
		II. Clinical Significance
			A. Individual Findings
			B. Laennec Versus Modern Studies
			C. Combined Findings
			D. Pneumonia and Prognosis
			E. Hospital Course
		References
	Chapter 33: Chronic Obstructive Lung Disease
		I. Introduction
		II. The Findings
			A. Inspection
				1. Inspiratory Recession of Supraclavicular Fossa and Intercostal Spaces
				2. Costal Paradox (Hoover Sign, Costal Margin Paradox)
				3. Leaning Forward on Arms Propped Up on Knees
			B. Palpation: Laryngeal Height and Descent
		III. Clinical Significance
			A. Individual Findings
			B. Combined Findings
			C. Prognosis in Chronic Obstructive Pulmonary Disease Exacerbation (Blood Urea Nitrogen, Altered Mental Status, and Pulse-65 Score)
		References
	Chapter 34: Pulmonary Embolism
		I. Introduction
		II. The Findings
		III. Clinical Significance
			A. Individual Findings
			B. Combining Findings to Determine Clinical Probability of Embolism
		References
	Chapter 35: Pleural Effusion
		I. Introduction
		II. The Findings
		III. Clinical Significance
		References
Part 8: The Heart
	Chapter 36: Inspection of the Neck Veins
		I. Introduction
		II. Venous Pressure
			A. Definitions
				1. Central Venous Pressure
				2. Physiologic Zero Point
				3. External Reference Point
					a. Sternal Angle
					b. Phlebostatic Axis
					c. Relative Merits of Sternal Angle and Phlebostatic Axis
			B. Elevated Venous Pressure
				1. Technique
				2. External Versus Internal Jugular Veins
				3. Definition of Elevated CVP
			C. Bedside Estimates of Venous Pressure Versuscatheter Measurements
				1.  Diagnostic Accuracy
				2. Why Clinicians Underestimate Measured Values
			D. Clinical Significance of Elevated Venouspressure
				1. Differential Diagnosis of Ascites and Edema
				2. Elevated Venous Pressure and Left Heart Disease
				3. Elevated Venous Pressure During Preoperative Consultation
				4. Elevated Venous Pressure and Pericardial Disease
				5. Unilateral Elevation of Venous Pressure
			E. Clinical Significance of Low Estimated Venous Pressure
		III. Abdominojugular Test
			A. The Finding
			B. Clinical Significance
		IV. Kussmaul Sign
			A. Pathogenesis of Elevated Venous Pressure, Abdominojugular Test, and Kussmaul Sign
			B. Clinical Significant of Kussmaul Sign
		VI. Venous Waveforms
			A. Identifying the Internal Jugular Vein
			B. Components of Venous Waveforms
			C. Timing the X\' and Y Descents
				1. Using Heart Tones
				2. Using the Carotid Artery
			D. Clinical Significance
				1. Abnormal Descents
				2. Abnormally Prominent Outward Waves
					a. Giant A Waves (Abrupt Presystolic Outward Waves)
					b. Systolic Waves
						(1). Tricuspid Regurgitation
						(2). Cannon A Waves
							(a). Regular Cannon A Waves
							(b). Intermittent Cannon A Waves
		References
	Chapter 37: Percussion of the Heart
		I. Introduction
		II. Clinical Significance
		References
	Chapter 38: Palpation of the Heart
		I. Introduction
		II. Technique
			A. Patient Position
			B. Location of Abnormal Movements
			C. Making Precordial Movements More Conspicuous
		III. The Findings
			A. Normal
			B. Hyperkinetic
			C. Sustained
			D. Retracting
			E. Heaves, Lifts, and Thrusts
		IV. Clinical Significance
			A. Apex Beat
				1. Location
				2. Diameter of the Apical Impulse
				3. Abnormal Movements
					a. Hyperkinetic Apical Movements
					b. Sustained Apical Movements
					c. Retracting Apical Impulse
						(1). Constrictive Pericarditis
						(2). Tricuspid Regurgitation
			B. Left Lower Parasternal Movements
				1. Hyperkinetic Movements
				2. Sustained Movements
					a. Right Ventricle
					b. Left Atrium and Mitral Regurgitation
			C. Aneurysms
			D. Diffuse Precordial Movements
			E. Right Lower Parasternal Movements
			F. Palpable P2
			G. Palpable Third and Fourth Heart Sounds
		References
	Chapter 39: Auscultation of the Heart: General Principles
		I. Characteristics of Heart Soundsand Murmurs
		II. The Stethoscope
			A. Bell and Diaphragm
			B. Performance of Different Stethoscope Models
		III. Use of the Stethoscope
			A. Examination Room
			B. Bell Pressure
			C. Patient Position
			D. Order of Examination
			E. Describing the Location of Sounds
			F. Technique of Focusing
			G. Identifying Systole and Diastole
				1. Systole Is Shorter Than Diastole
				2. Characteristics of the First and Second Heart Sounds
				3. Carotid Impulse
		References
	Chapter 40: The First and Second Heart Sounds
		Introduction
		The First Heart Sound (S1)
			I. The Finding
			II. Pathogenesis
				A. Cause of S1
				B. Intensity of S1
					1. Ventricular Contractility
					2. Position of the Valve Leaflets at Onset of Ventricular Systole
			III. Clinical Significance
				A. Loud S1
					1. Vigorous Ventricular Contractions
					2. Delayed Closure of the Mitral Valve
						a. Prolapsed Mitral Valve
						b. Mitral Stenosis
						c. Left Atrial Myxoma
				B. Faint or Absent S1
					1. Weak Ventricular Contractions (Low dP/dt)
					2. Early Closure of the Mitral Valve
						a. Long PR Interval (>0.20 Seconds)
						B. Acute Aortic Regurgitation
				C. Varying Intensity of S1
				D. Prominent Splitting of S1
		The Second Heart Sound (S2)
			I. Introduction
			II. Normal Splitting of S2
				A. The Finding
				B. Location of Sound
				C. Technique
				D. Physiology of Splitting
			III. Abnormal Splitting of S2
				A. The Finding
					1. Wide Physiologic Splitting
					2. Wide Fixed Splitting
					3. Paradoxic Splitting (Reversed Splitting)
				B. Screening for Abnormal Splitting of S2
				C. Clinical Significance and Pathogenesis
					1. Wide Physiologic Splitting
					2. Wide and Fixed Splitting
					3. Paradoxic Splitting
				D. S2 Splitting Versus Other Double Sounds
					1. S2-opening Snap
					2. S2-pericardial Knock
					3. S2-third Heart Sound
					4. Late Systolic Click-S2
			IV. Intensity of S2
		References
	Chapter 41: The Third and Fourth Heart Sounds
		I. Introduction
		II. Definitions
			A. Gallop
			B. Third Heart Sound (S3)
			C. Fourth Heart Sound (S4)
			D. Summation Gallop
			E. Quadruple Rhythm
		III. Technique
			A. Location of Sound and Use of Stethoscope
			B. Right Versus Left Ventricular Gallops
			C. Distinguishing the S4-S1 Sound From Other Sounds
				1. Use of the Bell
				2. Location
				3. Effect of Respiration
				4. Palpation
		IV. Pathogenesis
			A. Normal Ventricular Filling Curves
			B. Ventricular Filling and Sound
			C. The Third Heart Sound (S3)
				1. Congestive Heart Failure
				2. Regurgitation and Shunts
			D. The Fourth Heart Sound (S4)
			E. Summation Gallop and Quadruple Rhythm
			F. Physiologic S3
		V. Clinical Significance
			A. The Third Heart Sound
				1. Congestive Heart Failure
				2. Valvular Heart Disease
				3. Patients with Acute Chest Pain
				4. Preoperative Consultation
			B. The Fourth Heart Sound
		References
	Chapter 42: Miscellaneous Heart Sounds
		Ejection Sounds
			I. The Finding and Pathogenesis
			II. Clinical Significance
		Mid-to-late Systolic Clicks
			I. The Finding and Pathogenesis
			II. Clinical Significance
		Opening Snap
			I. The Finding and Pathogenesis
			II. Clinical Significance
		Pericardial Knock
		Tumor Plop
		Prosthetic Heart Sounds
			I. Introduction
			II. Principles
				A. Opening and Closing Sounds
					1. Caged-ball Valves
					2. Tilting-disc Valves
				B. Murmurs
		References
	Chapter 43: Heart Murmurs: General Principles
		I. Introduction
		II. The Findings
			A. Basic Classification of Murmurs
				1. Systolic Murmurs
					a. Etiology
						(1). Abnormal Flow Over An Outflow Tract or Semi Lunar Valve
						(2). Regurgitation From a Ventricle Into a Low Pressure Chamber
					b. Older Classifications of Systolic Murmurs: “Ejection” and “Regurgitation” Murmurs
				2. Diastolic Murmurs
				3. Continuous Murmurs
			B. Location on the Chest Wall
			C. Specific Timing and Quality of Murmurs Using Onomatopoeia
			D. Grading the Intensity of Murmurs
		III. Clinical Significance
			A. Detecting Valvular Heart Disease
			B. Differential Diagnosis of Systolic Murmurs
				1. The Functional Murmur
				2. Identifying the Cause of Systolic Murmurs
					a. Distribution of Murmur (Murmur Pattern; See Fig. 43.1)
					b. Intensity of S1 and S2
					c. Timing, Radiation, and Quality of Sound (See Also the Section on Specific Timing and Quality of Murmurs Using Onomatopoeia)
					d. Intensity of Systolic Murmur During Irregular Rhythms
					e. Maneuvers
						(1). Respiration
						(2). Maneuvers Changing Venous Return
						(3). Maneuvers Changing Systemic Vascular Resistance (or Afterload)
		References
Part 9: Selected Cardiac Disorders
	Chapter 44: Aortic Stenosis
		I. Introduction
		II. The Findings
			A. The Murmur
			B. Associated Cardiac Signs
		III. Clinical Significance
			A. Detecting Aortic Stenosis
			B. Severity of Aortic Stenosis
				1. Individual Findings
				2. Why Positive Likelihood Ratios Are So Low
				3. Combined Findings
		References
	Chapter 45: Aortic Regurgitation
		I. Introduction
		II. The Findings
			A. The Murmur(s)
				1. Early Diastolic Murmur of Regurgitation
				2. Systolic Aortic Flow Murmur
				3. Apical Diastolic Rumble: Austin Flint Murmur
					a. Definition
					b. Pathogenesis
			B. Water Hammer Pulse and Increased Pulse Pressure
			C. Abnormal Pulsations of Other Structures: The Aortic Regurgitation Eponyms
			D. Hill Test
			E. Auscultation Over Arteries
				1. Pistol-shot Sound
					a. Definition
					b. Pathogenesis
				2. Duroziez Murmur or Sign
					a. Definition
					b. Pathogenesis
		III. Clinical Significance
			A. Detecting Aortic Insufficiency
			B. Distinguishing Aortic Valve Disease From Aortic Root Disease
			C. Distinguishing Aortic Regurgitation From Pulmonary Regurgitation
			D. Severity of Aortic Regurgitation
				1. The Diastolic Murmur
				2. Blood Pressure
				3. Hill Test
				4. Other Signs
			E. Acute Aortic Regurgitation
			F. Distinguishing the Austin Flint Murmur From Mitral Stenosis
		References
	Chapter 46: Miscellaneous Heart Murmurs
		Hypertrophic Cardiomyopathy
			I. The Murmur
			II. Associated Findings
		Mitral Regurgitation
			I. The Finding
				A. The Murmur
				B. Associated Findings
			II. Clinical Significance
				A. Detecting Mitral Regurgitation
				B. Severity of Mitral Regurgitation
					1. The Murmur
					2. Other Findings
				C. Distinguishing Acute From Chronic Mitral Regurgitation
				D. Papillary Muscle Dysfunction
		Mitral Valve Prolapse
			I. Introduction
			II. The Findings
				A. The Murmur
				B. The Clicks
				C. Response of Murmurs and Clicks to Maneuvers
			III. Clinical Significance
				A. Detection of Mitral Valve Prolapse
				B. Risk of Significant Mitral Regurgitation
		Tricuspid Regurgitation
			I. The Findings
				A. The Murmur
					1. High-pressure Tricuspid Regurgitation
					2. Low-pressure Tricuspid Regurgitation
				B. Other Findings
					1. High-pressure Tricuspid Regurgitation
					2. Low-pressure Tricuspid Regurgitation
				C. Estimating Venous Pressure in Tricuspid Regurgitation
			II. Clinical Significance
				A. Detecting Tricuspid Regurgitation
				B. Severity of Tricuspid Regurgitation
		Pulmonic Regurgitation
			I. The Finding
				A. High-pressure Pulmonic Regurgitation
				B. Low-pressure Pulmonic Regurgitation
			II. Clinical Significance
				A. Detecting Pulmonic Regurgitation
				B. Detecting Pulmonary Hypertension
				C. Hemodialysis Patients
		Mitral Stenosis
			I. The Findings
				A. The Murmur
				B. Other Cardiac Findings
			II. Clinical Significance
				A. The Murmur
				B. Other Cardiac Findings
		Arteriovenous Fistulae: The Hemodialysis Fistula
		References
	Chapter 47: Disorders of the Pericardium
		Pericarditis and the Pericardial Rub
			I. Introduction
			II. The Finding
			III. Clinical Significance
				A. The Rub and Pericarditis
				B. The Rub and Pericardial Effusion
				C. The Rub and Neoplastic Disease
				D. The Rub and Myocardial Infarction
		Cardiac Tamponade
			I. Introduction
			II. The Findings
		Constrictive Pericarditis
			I. Introduction
			II. The Findings
				A. Neck Veins
				B. Kussmaul Sign
				C. Pericardial Knock
				D. Other Findings
		References
	Chapter 48: Congestive Heart Failure
		I. Introduction
		II. The Findings
		III. The Valsalva Response
			A. Introduction
			B. Technique
			C. The Normal Valsalva Response
			D. The Abnormal Valsalva Response
			E. Pathogenesis of the Abnormal Valsalva Response
		IV. Clinical Significance
			A. Detecting Elevated Left Heart Filling Pressures
			B. Detecting Depressed Left Ventricular Ejection Fraction
			C. Proportional Pulse Pressure
			D. Physical Signs and Consensus Diagnosis of Congestive Heart Failure
			E. Prognosis in Heart Failure
		References
	Chapter 49:  Coronary Artery Disease
		I. Introduction
		II. The Findings
			A. Introduction
			B. Description of Chest Pain
			C. Hand Gestures During Description of Chest Pain
			D. Physical Findings
				1. Earlobe Crease
				2. Arcus Senilis
				3. Ankle-to-arm Pressure Index
			E. GI Cocktail
		III. Clinical Significance
			A. Diagnosing Coronary Artery Disease
			B. Diagnosing Myocardial Infarction
			C. Risk Factors and Coronary Disease
			D. GI Cocktail
			E. Prognosis and Acute Chest Pain
		References
Part 10: Abdomen
	Chapter 50: Inspection of the Abdomen
		Ecchymosis of the Abdominal Wall
			I. The Findings
			II. Pathogenesis
		Sister Mary Joseph Nodule
			I. The Finding
			II. Pathogenesis
		References
	Chapter 51:  Palpation and Percussion of the Abdomen
		I. Introductory Comments on Technique
		II. Liver
			A. Liver Span
				1. The Finding
				2. Clinical Significance
			B. Palpable Liver Edge
				1. The Finding
				2. Clinical Significance
					a. Detection of Hepatomegaly
					b. Palpable Liver and Other Disorders
			C. Auscultatory Percussion—Scratch Test
				1. the Finding
				2. Clinical Significance
			D. Pulsatile Liver
		III. The Spleen
			A. Palpable Spleen
				1. The Finding
				2. Clinical Significance
					a. Detection of Splenomegaly
					b. Etiology of Splenomegaly
					c. Palpable Spleen and Other Disorders
			B. Splenic Percussion Signs
				1. The Findings
					a. Spleen Percussion Sign
					b. Nixon Method
					c. Traube Space Dullness
				2. Clinical Significance
		IV. Gallbladder: Courvoisier Sign
			A. The Finding
			B. Clinical Significance
			C. Pathogenesis
		V. Bladder Volume
		VI. Ascites
			a. The Findings
			B. Pathogenesis
			C. Clinical Significance
		VII. Abdominal Aortic Aneurysm
			A. Introduction
			B. The Finding
			C. Clinical Significance
		References
	Chapter 52: Abdominal Pain and Tenderness
		Acute Abdominal Pain
			I. Introduction
			II. The Findings
				A. Peritonitis
					1. Guarding and Rigidity
					2. Rebound Tenderness
					3. Percussion Tenderness
					4. Cough Test
					5. Abdominal Wall Tenderness Test
				B. Appendicitis
					1. Mcburney Point Tenderness
					2. Rovsing Sign (Indirect Tenderness)
					3. Rectal Tenderness
					4. Psoas Sign
					5. Obturator Sign
				C. Cholecystitis and Murphy Sign
				D. Small Bowel Obstruction
			III. Clinical Significance
				A. Peritonitis (See EBM Box 52.1)
				B. Special Tests for Appendicitis
					1. Individual Findings (See EBM Box 52.2)
					2. Combination of Findings: The Alvarado Score
				C. Cholecystitis (See EBM Box 52.3)
				D. Small Bowel Obstruction (See EBM Box 52.4)
				E. Diverticulitis
				F. Renal Colic
		Chronic Abdominal Pain
		References
	Chapter 53: Auscultation of the Abdomen
		Abdominal Bruits
			I. The Finding
			II. Clinical Significance
				A. Bruits in Healthy Persons
				B. Bruits in Renovascular Hypertension
				C. Other Disorders
		Hepatic Rub
		Bowel Sounds
			I. The Finding
			II. Clinical Significance
		References
Part 11: Extremities
	Chapter 54: Peripheral Vascular Disease
		I. Introduction
		II. The Findings
			A. Appearance of the Foot
			B. Pulses
			C. Bruits
			D. Ancillary Tests
				1. Venous Filling Time
				2. Capillary Refill Time
				3. Buerger Test
		III. Clinical Significance
			A. Diagnosis of Peripheral Vascular Disease
			B. Distribution of Peripheral Vascular Disease
			C. Complications of Arterial Puncture
			D. Detecting Hypoperfusion in Intensive Care Unit
		References
	Chapter 55:  the Diabetic Foot
		I. Introduction
		II. The Findings
			A. Foot Ulceration
			B. Diabetic Neuropathy and Semmes-Weinstein Monofilaments
			C. Charcot Joint
			D. Osteomyelitis
		III. Clinical Significance
			A. The Semmes-Weinstein Monofilament
			B. Osteomyelitis
			C. Predictors of Nonhealing Wounds
		References
	Chapter 56: Edema and Deep Vein Thrombosis
		Edema
			I. Introduction
			II. The Findings
			III. Clinical Significance
				A. Pitting Edema
				B. Lymphedema
		Deep Vein Thrombosis
			I. Introduction
			II. The Findings
				A. Inspection and Palpation
				B. Homans Sign
				C. Pseudothrombophlebitis
			III. Clinical Significance
				A. Individual Findings
				B. Combined Findings
				C. Diagnosing Upper Extremity Deep Venous Thrombosis
		References
	Chapter 57: Examination of the Musculoskeletal System
		The Shoulder
			I. Introduction
			II. The Findings
				A. Impingement Signs
				B. Yergason Sign
				C. Speed Test
				D. Muscle Atrophy
				E. Muscle Testing
				F. Dropped Arm Test
				G. Palpating Rotator Cuff Tears
				H. Crossed Body Adduction Test (Scarf Test)
			III. Clinical Significance
				A. Acromioclavicular Joint Pain
				B. Rotator Cuff Tendonitis
				C. Rotator Cuff Tears
					1. Individual Findings
					2. Combined Findings
		The Hip
			I. Introduction
			II. The Findings
			III. Clinical Significance
		The Knee
			I. Introduction
			II. The Findings
				A. Ottawa Rules for Knee Fracture
				B. Tests of Ligament Injuries
					1. Anterior Cruciate Ligament
					2. Posterior Cruciate Ligament
					3. Collateral Ligaments
				C. Tests of Meniscal Injuries: the McMurray Test
			III. Clinical Significance
				A. Detecting Osteoarthritis
				B. Detecting Knee Fracture
				C. Detecting Ligament and Meniscal Injuries
					1. Anterior Cruciate Ligament Injury
					2. Posterior Cruciate Tear
					3. Mensical Injury
					4. Collateral Ligaments
					5. Variables Affecting Sensitivity of Signs
					6. Predicting the Need for Knee Surgery
		The Ankle
			I. Introduction
			II. The Finding
				A. Ottawa Ankle and Midfoot Rules
				B. Achilles Tendon Rupture
			III. Clinical Significance
				A. Ankle and Midfoot Fractures
				B. Achilles Tendon Rupture
		References
Part 12: Neurologic Examination
	Chapter 58: Visual Field Testing
		I. Introduction
		II. Definition
		III. The Anatomy of the Visual Pathways
		IV. Technique
			A. Static Technique
			B. Kinetic Technique
		V. The Findings
			A. Anterior or Prechiasmal Defects
			B. Chiasmal Defects
			C. Postchiasmal Defects
		VI. Clinical Significance
			A. Etiology
			B. Diagnostic Accuracy
			C. Differential Diagnosis of Postchiasmal Defects
			D. Improving Detection of Visual Field Defects
		References
	Chapter 59: Nerves of the Eye Muscles (III, IV, and VI): Approach to Diplopia
		Diplopia
			I. Introduction
			II. Definitions
			III. Technique
				A. General Approach
				B. Identifying the Weak Muscle
			IV. Clinical Significance
				A. Monocular Diplopia
				B. Binocular Diplopia
					1. Etiology
					2. Weak Muscles and Their Clinical Significance
						a. Weak Superior Rectus Muscle
						b. Weak Inferior Rectus Muscle
							(1). Thyroid Myopathy
							(2). Orbital Fracture
						c. Weak Medial Rectus
							(1). Internuclear Ophthalmoplegia
							(2). Myasthenia Gravis
						d. Weak Lateral Rectus
						e. Weak Superior Oblique
						f. Weak Inferior Oblique
					3. Skew Deviation
				C. Ice Pack Test for Myasthenia Gravis
		Disorders of Cranial Nerves III, IV, and VI
			I. Introduction
			II. Rules for Diagnosing Ischemic Infarcts
			III. Oculomotor Nerve (Cranial Nerve III)
				A. The Finding
				B. Clinical Significance
					1. Pupil-sparing Rule
					2. Clinical Syndromes
						a. Ipsilateral Brainstem Injury
						b. Injury to the Nerve in the Subarachnoid Space
						c. Ipsilateral Cavernous Sinus or Orbit Injury
						d. Ischemic Infarcts
			IV. Trochlear Nerve (Cranial Nerve IV)
				A. The Finding
					1. Isolated IV Palsy
					2. Combined III and IV Palsy
				B. Clinical Significance
					1. Head Position
					2. Clinical Syndromes
						a. Contralateral Midbrain Injury
						b. Ipsilateral Cavernous Sinus or Orbit Injury
						c. Ischemic Infarcts
			V. Abducens Nerve (Cranial Nerve VI)
				A. The Finding
				B. Clinical Significance
		References
	Chapter 60: Miscellaneous Cranial Nerves
		Olfactory Nerve (I)
			I. Technique
			II. Clinical Significance
				A. Anosmia
				B. Olfactory Dysfunction
		Trigeminal Nerve (V)
			I. Introduction
			II. The Finding
				A. Motor Weakness
				B. Sensory Loss
				C. Corneal Reflex
			III. Clinical Significance
				A. Motor Weakness
				B. Sensory Loss
					1. Sensory Loss of Face and Body
					2. Sensory Loss Isolated to the Face
				C. Abnormal Corneal Reflex
				D. Herpes Zoster Infection and the Nasociliary Branch of the Trigeminal Nerve (“Hutchinson Sign”)
		Facial Nerve (VII)
			I. The Finding
			II. Clinical Significance
				A. Central Versus Peripheral Facial Weakness
				B. Peripheral Nerve Lesions
					1. Etiology
					2. Associated Findings
					3. Topographic Diagnosis
					4. Complications of Bell Palsy
		Glossopharyngeal (IX) and Vagus (X) Nerves
			I. Finding
			II. Clinical Significance
				A. Bilateral Cerebral Hemispheric Lesions: Pseudobulbar Palsy
				B. Bedside Predictors of Risk of Aspiration After Stroke
				C. Lesions of Ipsilateral Brainstem or Peripheral Nerve
		Spinal Accessory Nerve (XI)
			I. Finding
			II. Clinical Significance
				A. Cerebral Hemisphere
				B. Brainstem or High Cervical Spinal Cord
				C. Peripheral Nerve
		Hypoglossal Nerve (XII)
			I. Finding
			II. Clinical Significance
				A. Cerebral Hemisphere
				B. Brainstem
				C. Peripheral Nerve
		References
	Chapter 61: Examination of the Motor System: Approach to Weakness
		The Motor Examination
			I. Muscle Strength
				A. Definitions
				B. The Findings
					1. Technique
					2. Grading Muscle Strength
					3. Special Tests for Unilateral Cerebral Lesions
				C. Clinical Significance
			II. Atrophy and Hypertrophy
				A. Atrophy
					1. Definition
					2. Technique
					3. Clinical Significance
				B. Hypertrophy
			III. Fasciculations
				A. Definition
				B. Clinical Significance
			IV. Muscle Tone
				A. Increased Muscle Tone
					1. Spasticity
						a. Definition
						b. Characteristic Postures
						c. Clasp-knife Phenomenon
						d. Relationship of Spasticity to Weakness
					2. Rigidity
						a. Definition
						b. Distinguishing Spasticity From Rigidity
						c. Clinical Significance
					3. Paratonia
						a. Definition
						b. Technique
						c. Clinical Significance
				B. Decreased Muscle Tone: Hypotonia (Flaccidity)
					1. Definition
					2. Technique
					3. Clinical Significance
					4. Pathogenesis
			V. Muscle Percussion
				A. Percussion Myotonia
					1. The Finding
					2. Clinical Significance
				B. Myoedema
					1. The Finding
					2. Clinical Significance
		Approach to Weakness
			I. Cause of Weakness
			II. The Findings
				A. Upper Versus Lower Motor Neuron Lesions
					1. Associated Findings in the Weak Limb (See Table 61.2)
					2. Localizing Signs of Upper Motor Neuron Weakness
					3. Babinski Sign
					4. Distribution of Weakness
						a. Limbs Affected
						b. Movement Versus Muscle
				B. The Diagnostic Process
					1. Upper Motor Neuron Weakness
					2. Lower Motor Neuron Weakness
					3. Combined Upper and Lower Motor Neuron Weakness
						a. Myelopathy
						b. Amyotrophic Lateral Sclerosis
			III. Clinical Significance
				A. Clinical Syndromes Are Often Incomplete
				B. Proximal Weakness Indicates Muscle Disease
				C. the Special Tests for Cerebral Hemispheric Lesions Are Accurate
				D. Additional Signs Distinguishing Strokes of the Anterior Versus Posterior Circulation
				E. Diagnosis of Peripheral Nerve Disorders
		References
	Chapter 62: Examination of the Sensory System
		Simple Sensations
			I. Definitions
			II. Technique
				A. Touch
				B. Pain and Temperature
				C. Vibration
			III. Clinical Significance
				A. Touch, Pain, and Temperature Sensation
				B. Vibratory Sensation
				C. Hyperpathia and Allodynia Are Nonspecific Findings
		Proprioception
			I. Definition
			II. Technique
			III. Clinical Significance
		Cortical Sensations
			I. Definition
			II. Technique
				A. Two-point Discrimination
				B. Tactile Recognition (Stereognosis)
				C. Graphesthesia
				D. Localization
				E. Bilateral Simultaneous Tactile Stimulation
				F. Appreciation of Weights
			III. Clinical Significance
		Dermatomes
			I. Definition
			II. Derivation of the Dermatomal Maps
			III. Technique
			IV. Clinical Significance
				A. the Sensory Level in Spinal Cord Disease
				B. Dermatomal Loss in Radiculopathy
		Sensory Syndromes
			I. Technique
				A. Does the Sensory Loss Involve Both Sides of the Body
				B. Is There a Sensory Level
				C. Is There Sensory Dissociation
				D. Is There Sensory Loss on the Face
				E. Are There Associated Neurologic Signs
			II. Definition of the Sensory Syndromes
				A. Polyneuropathy
				B. Spinal Cord Syndromes
					1. Complete Spinal Cord Lesion
					2. Incomplete Spinal Cord Lesions
						a. Anterior Cord Syndrome
						b. Brown-Séquard Syndrome
						c. Central Cord Syndrome
				C. Lateral Medullary Infarction
				D. Thalamic Disease
				E. Cerebral Hemispheric Disease
		References
	Chapter 63: Examination of the Reflexes
		Reflex Hammers
			I. Types of Reflex Hammers
				A. Taylor Hammer
				B. Queen Square Hammer
				C. Babinski Hammer (Babinski/Rabiner Hammer)
				D. Troemner Hammer
			II. Clinical Significance
		Muscle Stretch Reflexes
			I. Definition
			II. Technique
				A. Method
				B. Grading Reflex Amplitude
				C. Reinforcement: The Jendrassik Maneuver
			III. Clinical Significance
				A. Amplitude of Reflex
				B. Localizing Value of Diminished Reflexes
				C. Ankle Jerk and Diabetic Peripheral Neuropathy
				D. Additional Findings in the Hyperreflexic Patient
					1. Finger Flexion Reflexes
					2. Jaw Jerk
					3. Clonus
					4. Irradiation of Reflexes
						a. Crossed Adductor Reflex
						b. Inverted Supinator Reflex
						c. Inverted Knee Jerk
		Cutaneous Reflexes (Superficial Reflexes)
			I. Definition
			II. Superficial Abdominal Reflex (T6 to T11)
				A. Technique
				B. Clinical Significance
			III. Bulbocavernosus Reflex (S2 to S4)
				A. Technique
				B. Clinical Significance
		Babinski Response
			I. Definition
			II. Pathogenesis
			III. Technique
				A. Eliciting the Response
				B. Interpreting the Response
			IV. Clinical Significance
				A. Associated Conditions
				B. False-negative Response
		Primitive Reflexes
			I. Definition
			II. Technique
				A. Palmomental Reflex
				B. Glabellar Reflex
				C. Grasp Reflex
			III. Clinical Significance
				A. General Comments
				B. Palmomental Reflex
				C. Glabellar Reflex
				D. Grasp Reflex
				E. Primitive Reflexes and Normal Aging
		References
	Chapter 64: Disorders of the Nerve Roots, Plexuses, and Peripheral Nerves
		I. Introduction
		II. The Arm
			A. Introduction
			B. Neurologic Findings
				1. Motor
					a. Radiculopathy
					b. Brachial Plexopathy
					c. Peripheral Nerve Disorders
				2. Sensory Findings
				3. Reflexes
				4. Provocative Tests
			C. Additional Diagnostic Clues
				1. The Clavicle
				2. Horner Syndrome (See Chapter 21)
			D. Clinical Significance
				1. Diagnosing Cervical Radiculopathy
				2. Localizing Cervical Radiculopathy
				3. Plexopathy in Cancer Patients
				4. Peripheral Nerve Injury: Diagnosis of Carpal Tunnel Syndrome
		III. The Leg
			A. Introduction
			B. Neurologic Findings
				1. Motor
					a. Radiculopathy
					b. Lumbosacral Plexopathy
					c. Peripheral Nerve Disorders
				2. Sensory Findings
				3. Reflexes
				4. Provocative Tests
			C. Clinical Significance
				1. Lumbosacral Radiculopathy
				2. Lumbosacral Plexopathy
					a. Cancer Patients
					b. Diabetic Amyotrophy
		References
	Chapter 65: Coordination and Cerebellar Testing
		I. Introduction
		II. The Findings
			A. Ataxia
				1. Finger-nose-finger Test
				2. Heel-knee-shin Test
			B. Nystagmus
				1. Definition
				2. Patterns of Nystagmus
					a. Cerebellar Nystagmus
					b. Nystagmus and Noncerebellar Disorders
				3. Effect of Retinal Fixation
			C. Hypotonia (See Chapter 61)
			D. Dysarthria
		III. Clinical Significance
			A. Individual Findings
				1. Ataxia
				2. Nystagmus
				3. Dysarthria
			B. Cerebellar Syndromes
				1. Cerebellar Hemisphere Syndrome
					a. Cerebellar Findings
					b. Associated Findings
				2. Anterior Cerebellar Degeneration (Rostral Vermis Syndrome)
				3. Pancerebellar Syndrome
				4. Cerebellar Infarction
		References
Part 13: Selected Neurologic Disorders
	Chapter 66: Tremor and Parkinson Disease
		I. Introduction
		II. The Finding
			A. Tremor
			B. Bradykinesia
			C. Atypical Features of Parkinson Disease
			D. Tandem Gait Testing
			E. Applause Sign (Clapping Test)
		III. Clinical Significance: Diagnosing Parkinson Disease
		References
	Chapter 67: Hemorrhagic Versus Ischemic Stroke
		I. Introduction
		II. Findings
		III. Clinical Significance
			A. Symptoms
			B. Individual Physical Findings
			C. Combined Findings (Siriraj Stroke Score)
		References
	Chapter 68: Acute Vertigo and Imbalance
		I. Introduction
		II. The Findings
			A. The Vestibuloocular Reflex
			B. Head Impulse Test (Fig. 68.2)
			C. Skew Deviation
			D. Abnormal Visual Tracking: Saccadic Pursuit
			E. Direction-changing Nystagmus (Fig. 68.3)
		III. Clinical Significance
			A. Individual Findings
			B. Combined Findings
		References
	Chapter 69: Examination of Nonorganic Neurologic Disorders
		I. Traditional Physical Findings of Nonorganic Disease
			A. Findings Whose Severity Fluctuates During the Examination
			B. Findings That Defy Neuroanatomic Explanation
			C. Bizarre Movements Not Normally Seen in Organic Disease
			D. Findings Elicited During Special Tests
		II. Clinical Significance
			A. Diagnostic Accuracy
			B. Caveats to the Diagnosis of Nonorganic Disorders
		References
Part 14: Examination in the Intensive Care Unit
	Chapter 70: Examination of Patients in the Intensive Care Unit
		I. Introduction
		II. The Findings
			A. Modified Early Warning Score (Table 70.1)
			B. Assessment of Peripheral Perfusion in the ICU
			C. Pulse Pressure Changes with Passive Leg Elevation (Hypovolemia)
		III. Clinical Significance
			A. Modified Early Warning Score
			B. Septic Shock and Cardiogenic Shock
			C. Pulse Pressure Changes with Passive Leg Elevation (Hypovolemia)
			D. Assessment of Peripheral Perfusion in the Intensive Care Unit
			E. Lung Findings
			F. Neurologic Findings
		References
Appendix: Likelihood Ratios, Confidence intervals, and Pre-test Probability