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• Cover
• Title Page
• Copyright
• Dedication
• Faculty Reviewers and Additional Contributors
• Preface
• Contents
• CHAPTER 1: Approach to the Clinical Encounter
• APPROACH TO THE CLINICAL ENCOUNTER
• General Structure and Sequence of the Clinical Encounter
• DISPARITIES IN HEALTH CARE
• Social Determinants of Health
• OTHER MAJOR CONSIDERATIONS
• Spirituality
• Medical Ethics
• Decisional Capacity
• APPROACH TO A CLINICAL ETHICAL DILEMMA
• DOCUMENTING THE CLINICAL ENCOUNTER
• Quality Clinical Record
• INTERPRETATION AIDS
• CHAPTER 2: Interviewing, Communication, and Interpersonal Skills
• FUNDAMENTALS OF SKILLED INTERVIEWING
• Empower the Patient
• Use Understandable Language
• Use Nonstigmatizing Language
• Use Appropriate Nonverbal Communication
• OTHER CONSIDERATIONS
• Broaching Sensitive Topics
• Obtaining Informed Consent
• Working with a Medical Interpreter
• Obtaining Advance Directives
• Disclosing Serious News
• Building Interprofessional Communication
• CHALLENGING ENCOUNTERS
• MAINTAINING PATIENT-CENTEREDNESS IN COMPUTERIZED CLINICAL SETTINGS
• CHAPTER 3: Health History
• COMPREHENSIVE ADULT HEALTH HISTORY
• Chief Complaint(s)
• History of Present Illness
• Past Medical History
• Family History
• Personal and Social History
• Review of Systems (ROS)
• Modification of the Clinical Interview for Various Clinical Settings
• DOCUMENTING THE HEALTH HISTORY
• Documenting the Chief Complaint
• Documenting the History of Present Illness
• Documenting the Past Medical History
• CHAPTER 4: Physical Examination
• COMPREHENSIVE PHYSICAL EXAMINATION
• Beginning the Examination: Setting the Stage
• Suggested “Head-to-Toe” Physical Examination
• DOCUMENTING THE PHYSICAL EXAMINATION
• CHAPTER 5: Clinical Reasoning, Assessment, and Plan
• Gather Initial Patient Information
• Organize and Interpret Clinical Information
• Synthesize Clinical Information and Develop the Problem Representation
• Generate Hypotheses by Searching for the Probable Cause of the Findings
• Test Your Hypotheses
• Establish a Working Diagnosis
• Plan the Diagnostic and Treatment Strategy
• DOCUMENTING THE SUMMARY STATEMENT, ASSESSMENT, AND PLAN
• Documenting the Summary Statement
• Documenting the Assessment and Plan
• PATIENT PROBLEM LIST
• PROGRESS NOTE
• ORALLY COMMUNICATING THE CLINICAL ENCOUNTER
• CHAPTER 6: Health Maintenance and Screening
• CONCEPT OF PREVENTIVE CARE
• GUIDELINE RECOMMENDATIONS
• SCREENING
• Screening Guidelines for Adults
• Behavioral Counseling
• Behavioral Counseling Guidelines for Adults
• Screening and Behavioral Counseling Guidelines for Adults
• Immunization
• PREVENTIVE CARE IN SPECIAL POPULATIONS
• CHAPTER 7: Evaluating Clinical Evidence
• USING ELEMENTS OF THE HISTORY AND PHYSICAL EXAMINATION AS DIAGNOSTIC TESTS
• EVALUATING DIAGNOSTIC TESTS
• Validity
• Reproducibility
• CRITICAL APPRAISAL OF THE CLINICAL EVIDENCE
• Are the Results Valid?
• What Are the Results?
• Can You Apply the Results to Patient Care?
• CHAPTER 8: General Survey, Vital Signs, and Pain
• HEALTH HISTORY
• Fatigue and Weakness
• Fever, Chills, and Night Sweats
• Weight Change
• Pain
• TECHNIQUES OF EXAMINATION
• General Survey
• Height and Weight
• Vital Signs: Blood Pressure, Heart Rate, Respiratory Rate, and Temperature
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Screening for Hypertension
• Blood Pressure and Dietary Sodium
• INTERPRETATION AIDS
• CHAPTER 9: Cognition, Behavior, and Mental Status
• HEALTH HISTORY
• Anxiety, Excessive Worrying
• Depressed Mood
• Memory Problems
• Patients with Medically Unexplained Symptoms
• MENTAL HEALTH SCREENING
• TECHNIQUES OF EXAMINATION
• Appearance and Behavior
• Speech and Language
• Mood
• Thought and Perceptions
• Cognitive Functions
• Higher Cognitive Functions
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Screening for Depression
• Assessing for Suicide Risk
• Screening for Neurocognitive Disorders
• Mental Disorders and Substance Use Disorders
• INTERPRETATION AIDS
• CHAPTER 10: Skin, Hair, and Nails
• HEALTH HISTORY
• Lesions
• Rashes and Itching (Pruritus)
• Hair Loss or Nail Changes
• TECHNIQUES OF EXAMINATION
• Standard Technique: Patient Position—Seated then Standing
• Alternative Technique: Patient Position—Supine then Prone
• Integrated Skin Examinations
• Special Techniques
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Skin Cancer Prevention
• Skin Cancer Screening
• INTERPRETATION AIDS
• CHAPTER 11: Head and Neck
• HEALTH HISTORY
• Neck Mass or Lump
• Thyroid Mass, Nodule, or Goiter
• TECHNIQUES OF EXAMINATION
• Head
• Neck
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Screening for Thyroid Dysfunction
• Screening for Thyroid Cancer
• Oral Health
• INTERPRETATION AIDS
• CHAPTER 12: Eyes
• HEALTH HISTORY
• Change in Vision
• Eye Pain, Redness, or Tearing
• Double Vision (Diplopia)
• TECHNIQUES OF EXAMINATION
• Visual Acuity
• Visual Fields by Confrontation
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Visual Impairment
• Screening for Glaucoma
• INTERPRETATION AIDS
• CHAPTER 13: Ears and Nose
• HEALTH HISTORY
• Ears
• Nose and Sinuses
• TECHNIQUES OF EXAMINATION
• Ears
• Nose and Sinuses
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Hearing Loss
• INTERPRETATION AIDS
• CHAPTER 14: Throat and Oral Cavity
• HEALTH HISTORY
• Sore Throat
• Gum Bleeding
• Hoarseness
• Malodorous Breath
• TECHNIQUES OF EXAMINATION
• Mouth
• Pharynx
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Oral Health
• Oral and Pharyngeal Cancer
• INTERPRETATION AIDS
• CHAPTER 15: Thorax and Lungs
• HEALTH HISTORY
• Shortness of Breath (Dyspnea)
• Wheezing
• Cough and Hemoptysis
• Daytime Sleepiness, Snoring, and Disordered Sleep
• Chest Pain
• TECHNIQUES OF EXAMINATION
• Thorax
• Posterior Chest
• Anterior Chest
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Lung Cancer
• Latent Tuberculosis
• Screening for Obstructive Sleep Apnea
• INTERPRETATION AIDS
• CHAPTER 16: Cardiovascular System
• HEALTH HISTORY
• Chest Pain
• Shortness of Breath
• Palpitations
• Swelling and Fainting
• TECHNIQUES OF EXAMINATION
• Heart Rate and Blood Pressure
• Jugular Veins
• Carotid Pulse
• Heart
• Special Techniques
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Screening for Cardiovascular Risk Factors
• Promoting Lifestyle Change and Risk Factor Modification
• INTERPRETATION AIDS
• CHAPTER 17: Peripheral Vascular System
• HEALTH HISTORY
• Pain and Swelling in Arms and Legs
• Cramping in Legs on Exertion and Relief with Rest (Intermittent Claudication)
• Cold, Numbness, Pallor, or Discoloration in Legs; Hair Loss
• Abdominal, Flank, or Back Pain
• TECHNIQUES OF EXAMINATION
• Arms
• Abdomen
• Legs
• Special Techniques
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Screening for Peripheral Arterial Disease
• Screening for Abdominal Aortic Aneurysm
• INTERPRETATION AIDS
• CHAPTER 18: Breasts and Axillae
• HEALTH HISTORY
• Breast Lump or Mass
• Breast Discomfort or Pain
• Nipple Discharge
• TECHNIQUES OF EXAMINATION
• Female Breast
• Male Breast
• Axillae
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Breast Cancer Risk Assessment
• Breast Cancer Screening
• INTERPRETATION AIDS
• CHAPTER 19: Abdomen
• HEALTH HISTORY
• Mechanisms of Abdominal Pain
• Gastrointestinal Tract
• Urinary Tract
• TECHNIQUES OF EXAMINATION
• Abdomen
• Liver
• Spleen
• Kidneys
• Aorta
• Special Techniques
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Viral Hepatitis: Risk Factors, Screening, and Vaccination
• Screening for Colorectal Cancer
• INTERPRETATION AIDS
• CHAPTER 20: Male Genitalia
• HEALTH HISTORY
• Penile Discharge or Lesions
• Scrotal or Testicular Swelling or Pain
• TECHNIQUES OF EXAMINATION
• Male Genitalia
• Special Technique
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Screening for Testicular Cancer
• INTERPRETATION AIDS
• CHAPTER 21: Female Genitalia
• HEALTH HISTORY
• Menarche, Menstruation
• Menopause, Postmenopausal Bleeding
• Vulvovaginal Symptoms
• Pelvic Pain
• TECHNIQUES OF EXAMINATION
• External Genitalia
• Internal Examination and Pap Smear
• Special Techniques
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Cervical Cancer Prevention
• Cervical Cancer Screening
• Menopause and Hormone Replacement Therapy
• INTERPRETATION AIDS
• CHAPTER 22: Anus, Rectum, and Prostate
• HEALTH HISTORY
• Change in Bowel Habits
• Blood in Stool
• Pain with Defecation, Rectal Tenderness
• Anal Warts or Fissures
• Weak Urinary Stream
• TECHNIQUES OF EXAMINATION
• Patient with a Prostate
• Female Patient
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Prostate Cancer Screening
• INTERPRETATION AIDS
• CHAPTER 23: Musculoskeletal System
• FUNDAMENTALS FOR ASSESSING JOINTS
• HEALTH HISTORY
• Joint Pain
• Neck Pain
• Low Back Pain
• TECHNIQUES OF EXAMINATION
• Steps for Examining Joints
• Temporomandibular Joint
• Shoulders
• Elbows
• Wrists and Hands
• Spine
• Hips
• Knees
• Ankles and Feet
• Special Techniques
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Low Back Pain
• Osteoporosis: Risk Factors, Screening, and Assessing Fracture Risk
• Treating Osteoporosis and Preventing Falls
• INTERPRETATION AIDS
• CHAPTER 24: Nervous System
• FUNDAMENTALS FOR ASSESSING THE NERVOUS SYSTEM
• Central Nervous System
• Peripheral Nervous System
• HEALTH HISTORY
• Headache
• Dizziness or Vertigo
• Numbness, Abnormal or Lost Sensations
• Weakness
• Near Syncope or Syncope
• Seizure
• Tremors or Involuntary Movements
• TECHNIQUES OF EXAMINATION
• Mental Status
• Cranial Nerves
• Motor System
• Sensory System
• Muscle Stretch Reflexes
• Cutaneous or Superficial Stimulation Reflexes
• Special Techniques
• Assessing the Patient Who Is Comatose
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Preventing Cerebrovascular Disease
• Screening for Asymptomatic Carotid Artery Stenosis
• Screening for Diabetic Peripheral Neuropathy
• INTERPRETATION AIDS
• CHAPTER 25: Children: Infancy through Adolescence
• GENERAL PRINCIPLES OF CHILD DEVELOPMENT
• Surveillance of Development
• PEDIATRIC CLINICAL ENCOUNTER
• General Outline
• Pediatric Health History
• NEWBORNS AND INFANTS HEALTH HISTORY: GENERAL APPROACH
• TECHNIQUES OF EXAMINATION
• Assessment at Birth
• Assessment Several Hours After Birth
• Mental and Physical Status
• General Survey
• Height and Weight
• Head Circumference
• Vital Signs
• Skin
• Head
• Eyes
• Ears
• Nose
• Mouth and Pharynx
• Neck
• Thorax and Lungs
• Heart and Peripheral Vascular System
• Breasts
• Abdomen
• Male Genitalia
• Female Genitalia
• Rectum and Anus
• Musculoskeletal System
• Nervous System
• YOUNG AND SCHOOL-AGED CHILDREN, HEALTH HISTORY: GENERAL APPROACH
• TECHNIQUES OF EXAMINATION
• Mental and Physical Status
• Eyes
• Special Techniques
• Ears
• Mouth and Pharynx
• Heart
• Abdomen
• Male Genitalia
• Female Genitalia
• Rectum and Anus
• Musculoskeletal System
• Nervous System
• ADOLESCENTS, HEALTH HISTORY: GENERAL APPROACH
• HEEADSSS Assessment
• Surveillance of Development: 11 to 20 Years
• Gender and Sexual Identity Formation Among Adolescents
• TECHNIQUES OF EXAMINATION
• Breasts
• Male and Female Genitalia
• Musculoskeletal System
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Key Principles of Health Promotion
• INTERPRETATION AIDS
• CHAPTER 26: Pregnant Woman
• CHANGES DURING PREGNANCY
• HEALTH HISTORY
• Confirmation of Pregnancy
• Gestational Age and Expected Date of Delivery
• Symptoms of Pregnancy
• Maternal Concerns and Attitudes
• Current Health and Past Clinical History
• Past Obstetric History
• Risk Factors for Maternal and Fetal Health
• Family History
• Plans for Genetic Testing and Aneuploidy Screening
• Plans for Breastfeeding
• Plans for Postpartum Contraception
• Subsequent Prenatal Visits
• TECHNIQUES OF EXAMINATION
• General Inspection
• Height, Weight, and Vital Signs
• Head and Neck
• Thorax and Lungs
• Heart
• Breasts
• Abdomen
• Genitalia, Anus, and Rectum
• Extremities
• Special Techniques
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• Nutrition and Weight Gain
• Exercise and Physical Activity
• Substance Use Including Tobacco, Alcohol, and Illicit Drugs
• Intimate Partner Violence Screening
• Screening for Perinatal Depression
• Immunizations
• Prenatal Laboratory Screenings
• Prenatal Supplementation
• Unintended Pregnancy
• INTERPRETATION AIDS
• CHAPTER 27: Older Adult
• DEMOGRAPHIC IMPERATIVE
• COMMUNICATING EFFECTIVELY WITH OLDER ADULTS
• Adjusting the Office Environment
• Shaping the Content and Pace of the Visit
• Eliciting Symptoms from the Older Adult
• ADDRESSING CULTURAL DIMENSIONS OF AGING
• HEALTH HISTORY
• Activities of Daily Living
• Medication Management
• Smoking and Alcohol
• Nutrition
• SPECIAL TOPICS IN OLDER ADULT CARE
• Frailty
• Advance Directives and Palliative Care
• TECHNIQUES OF EXAMINATION
• Assessing Functional Status
• General Survey
• Vital Signs
• Skin
• HEENT
• Thorax and Lungs
• Cardiovascular System
• Peripheral Vascular System
• Breasts and Axillae
• Abdomen
• Female Genitalia and Pelvic Examination
• Male Genitalia and Prostate
• Musculoskeletal System
• Nervous System
• RECORDING YOUR FINDINGS
• HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS
• When to Screen
• Screening for Vision and Hearing Impairments
• Exercise and Physical Activity
• Household Safety and Fall Prevention
• Immunizations
• Cancer Screening
• Detecting the “3 Ds”: Delirium, Dementia, and Depression
• Elder Mistreatment and Abuse
• INTERPRETATION AIDS
• INDEX