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2023 | Boek

Physical Diagnostics

The technique and significance of physical examination

Redacteuren: T.O.H. de Jongh MD, F.J. Jongen-Hermus MSc, J. Damen MD PhD, H.E.M. Daelmans MD PhD, R. Franssen MD PhD, I. de Klerk-van der Wiel MSc, A.D. Pieterse MD, B.J.J.W. Schouwenberg MD PhD, F. Schuring MD

Uitgeverij: Bohn Stafleu van Loghum


Over dit boek

Physical examination, along with history-taking, forms the basis of diagnosis. Interpretation of the information obtained will determine whether further diagnostic tests are worthwhile, and if so, which ones. This book provides students, lecturers and practising doctors with a standard for physical examination.

Physical Diagnostics describes physical examination systematically. The relevant anatomy and physiology are set out, as these provide the basis for the proper technique of physical examination. The book also provides information on normal and abnormal findings and their clinical significance. In addition to the systematic descriptions of adult examination there are chapters on the physical examination of specific groups such as pregnant women, newborn babies, children and geriatric patients.

Videos of all the procedures described have been made, over 150 clips in total. These can be viewed in the StudySuite online learning environment, where audio clips and the text of the book can also be found. StudySuite enables readers to switch easily between the videos and the text.

This new edition has been reorganized so as to make a clear distinction between general examination and examination on indication. There are new chapters on mental state examination, general physical examination in adults and chapters containing guidelines for communication and hygiene during physical examination. The text has been brought up to date and augmented where necessary, and many new illustrations have been included. There is a checklist for each chapter setting out the content of physical examination schematically.

Physical Diagnostics is intended primarily for medical students, specialist nurses and trainee medical specialists to learn physical examination systematically. It will also be found useful by doctors, lecturers and paramedical practitioners wishing to update and refresh their knowledge regarding the proper technique of physical examination and the clinical significance of abnormal findings.

The book has been produced in collaboration between the eight Dutch University Medical Centres and faculties, with input from Belgian colleagues.



Introductory chapters

1. Past, present and future of the physical examination
This chapter describes some high points in the history of physical examination, its place in clinical reasoning during the diagnostic process, and some future developments that supplement physical examination. A key feature of physical examination is that it has always been a very important diagnostic tool in addition to history-taking – not only in cases where diagnostic tests are not available (or not immediately), but also to enable the right diagnostic tests to be selected to make the diagnosis more or less likely. In some cases, physical examination provides direct diagnostic information that in fact obviates the need for tests. This creates a certain satisfaction and makes us once more aware of how valuable history-taking and physical examination, the basis of medical practice, are; moreover, they increase our pleasure in practising medicine.
A. J. Kooter
2. Hygiene and infection prevention during the physical examination
Staff of hospitals and other health care institutions need to work hygienically. Various hygiene standards are in force in health care institutions, and these will be different e.g. in nursing homes than in a hospital nursing ward to which patients are admitted for stem cell transplantation. It is important, therefore, to be aware of the latest national and local infection prevention guidelines. The main measure to prevent the transmission of microorganisms from staff to patients and vice versa is basic hygiene. This comprises (a) hand hygiene (how to practise it and the five occasions when it is required), (b) personal hygiene (e.g. not wearing hand or wrist jewellery and keeping uniforms closed), and (c) personal protective equipment, including gloves and face masks. Cleaning, disinfection and sterilisation are also important to break the chain of infection. Additional measures will sometimes be needed to prevent infection spreading, e.g. in line with isolation guidelines.
B. J. J. W. Schouwenberg, L. J. W. ten Horn-van Kreij
3. Basic techniques of physical examination
This chapter looks at the basic techniques required for physical examination: inspection, percussion, auscultation, palpation and the use of the stethoscope. We also discuss the problems that left-handed physicians have to contend with when carrying out physical examinations. More detailed information on the use of the various techniques can be found in other chapters.
A. J. Kooter, A. D. Pieterse
4. Communicating and dealing with patients during the physical examination
This chapter looks at communicating and dealing with patients during all the steps of a physical examination. How do you tell your patient what is going to happen, how do you give clear instructions during the examination and how do you ensure safety and comfort for the patient? We explore what findings you should disclose to the patient during the examination and how to do so. Another aspect we deal with is what to bear in mind regarding diversity in the consulting room. Lastly, we discuss what points to watch out for when there are other people in the examination room (e.g. partners or parents), when examining patients with a poor command of the language and when examining children.
W. E. S. van den Broek, I. M. E. Caubergh-Sprenger, F. J. M. Grosfeld
5. Reporting and the electronic health record
This chapter discusses the following topics. What is the purpose of reporting? Whom are the reports intended for? How do you write a clear report? What do you need to consider when entering it in the electronic health record? As well as the ‘classic’ medical record you will need e.g. to write summaries and case reports and give verbal patient presentations.
A. Thijs, A. J. Kooter, F. J. Jongen-Hermus
6. The value of diagnostic findings
Relatively little information on the value of physical examination is available, as this is a difficult subject to research. The research that has been done often shows high intra-rater and inter-rater agreement. A study (or combination of studies) yields a number (e.g. kappa or LR), which is referred to as the ‘point estimate’. The certainty or uncertainty of the point estimate is expressed as a p-value or confidence interval. Sensitivity and specificity are test properties that indicate how well a test differentiates between people who do and do not have the particular disease. These test properties are influenced by the degree of unwellness and the cut-off point selected for the test. The likelihood ratio (LR) combines sensitivity and specificity and is an important measure of a test or examination, indicating the extent to which the odds (and hence likelihood) of having the disorder are changed by the result of the test. The predictive value of a test, as well as the quality of the test, depends on the prior probability of having the disorder, and it can be difficult to estimate.
A. J. Kooter, T. O. H. de Jongh

General screening

7. Initial general examination
The doctor should observe the patient constantly during the consultation, watching how the patient behaves and thus forming a general impression of them. This process is partly conscious and partly unconscious. This chapter discusses the aspects that a doctor can observe. These observations are based on both objective data (blood pressure, oxygen saturation, abdominal girth, etc.) and more subjective information (behaviour, odour, affect, etc.). The doctor’s observations yield a general impression that can be useful to diagnosis, treatment and contact with the patient.
J. A. H. Eekhof, R. J. M. Claessen
8. The skin and lymph nodes
This chapter sets out what you need to look out for when examining the skin and lymph nodes. As regards the skin, you should pay attention to all the observable aspects, such as colour (e.g. cyanosis, jaundice, redness), skin abnormalities (haemorrhages, petechiae, purpura, ecchymosis or haematoma), scars, striae, itching or pruritus, effects of scratching, body hair (hair loss, hypertrichosis and hirsutism), abnormalities of the hands, fingers and nails, oedema, skin turgor and moist skin. Lastly, we describe how to examine the lymph nodes and the various things that you may observe when palpating them, with special reference to lymphadenopathy.
J. A. H. Eekhof, R. J. M. Claessen

Head and neck

9. The skull and face
The head is an area where problems can occur that fall into the province of various medical specialists. Some types of abnormality will be immediately visible (e.g. facial palsy or torticollis) and therefore easy to examine using inspection and palpation. Abnormalities of e.g. the skull bones and sensory functions (such as sight, smell, hearing and balance) will often not be so visible, in which case diagnostic tests may be required. Start your examination by assessing the position of the head relative to the trunk. This is followed by inspection, which requires a good light source. When palpating, pay particular attention to left-right differences and whether the abnormality is of the soft tissues or bones. Imaging may be required in the case of skull abnormalities. Examinations such as sinus auscultation and percussion are no longer standard practice.
L. de Rozario, F. W. G. Gruintjes
10. The eyes
An eye examination may be carried out in response to a specific eye or vision problem, or it may be part of a general, internal or neurological physical examination. This chapter discusses the types of eye examination that physicians and ophthalmologists have at their disposal. We start by considering the general eye examination, which comprises inspecting the external eye, testing pupil reflexes, ocular alignment and eye movements, and measuring the visual field and intraocular pressure. All these types of examination only require a penlight. More detailed ophthalmic tests require aids or tools (e.g. a visual acuity chart,a pinhole occluder, and a slit lamp or fundoscope). We explain each of these eye tests, where appropriate in relation to the problems with which patients present (e.g. red eye, double vision (diplopia), exophthalmos and enophthalmos). Lastly, we mention some important eye disorders (e.g. diabetic retinopathy, papilloedema, retinal detachment, hypopyon in the anterior chamber) that can be diagnosed using ophthalmic examination.
R. van Leeuwen
11. The ears
The ears are readily accessible to physical examination. Abnormalities of the external ear, eardrum and middle ear can be assessed by means of inspection using a light and an otoscope. An impression of the patient’s hearing and any hearing abnormalities can be gained using tuning fork tests. It is important to examine and compare both sides of the patient. Good lighting and correct positioning of the patient is important when carrying out the examination. Balance tests can be useful to examine disorders of the vestibular system and distinguish them from central nervous system disorders.
A. L. Smit, F. W. G. Gruintjes
12. The nose and sinuses
The external nose determines facial appearance to a large extent. Position, shape and size are important here and easy to examine. Patency is also important: this is determined by the position of the nasal septum, the thickness of the conchae and the nasal mucosa. A headlight is used for this examination, known as ‘anterior rhinoscopy’. The paranasal sinuses terminate in the lateral nasal wall. The mucus produced there flows through the ostia to the rear of the nose, moved by cilia. The paranasal sinuses can only be examined to a limited extent: endoscopy or X-ray examination will be required. The nose is highly vascularised, hence wounds usually heal well, but the good perfusion can make nose bleeds (epistaxis) severe. Smell is captured high in the nose by small nerve endings: these are branches of the olfactory nerve (N I) that pass through the lamina cribrosa (of the ethmoid bone).
A. van Wijck-Warnaar, F. W. G. Gruintjes
13. The mouth and oral cavity
This chapter describes the structure and various functions of the mouth and salivary glands. Structures considered to be part of the mouth are the lips, the teeth, the gingiva (gums), the mucous membranes of the oral cavity, the tonsils, the palate, the palatal arches, the uvula, the tongue, the lingual frenulum (tongue web), the posterior pharyngeal wall and the salivary glands. We explain how you can examine the mouth, considering its anatomy, motor function and sensation, and the appearance of the most common abnormalities and syndromes. Lastly, we explain in what cases you should suspect a malignancy.
A. van Wijck-Warnaar, F. W. G. Gruintjes
14. The neck
The neck is readily accessible to simple examination without aids, i.e. examination of the bony and cartilaginous structures, muscles, thyroid gland, lymph nodes and salivary glands. We give a clear explanation of the techniques required for palpation, the possible findings and what the obstacles are. Additional tests discussed include MRI, CT, fine needle aspiration cytology (FNAC), cone beam computed tomography (CBCT), contrast X-ray examination (sialography) and scintigraphy. The main neck abnormalities are swellings of the lymph nodes and thyroid gland. The lymph node and thyroid disorders discussed include hypothyroidism and hyperthyroidism, enlarged thyroid, thyroglossal cyst, goitre, thyroiditis (Hashimoto’s disease), lymphadenopathy, Graves’ disease, Plummer’s disease and malignancies.
J. A. Rijken, F. W. G. Gruintjes

The thorax

15. The anatomy of the thorax
The anatomy of the thorax comprises the content of the thoracic cavity and the thoracic cage/rib cage. The thoracic cavity contains the trachea and main bronchi, the lungs, the heart, the great arteries, the large veins, the mediastinum and the oesophagus. The thoracic cage comprises the sternum, the ribs and the clavicle, which is connected to the scapula at the back of the thorax by the pectoral girdle. Between the ribs are the intercostal spaces, each of which is named after the rib above it. The most commonly used reference point is the sternal angle, palpable as an irregular line, to which the second rib is attached at the side. Imaginary vertical lines on the thorax can be used to locate the organs in the thoracic cavity.
H. H. M. Al-Itejawi, E. L. van Veen, M. Vanaeken, J. Iwema
16. The heart
This chapter describes the physical examination of the heart. In order to understand the significance of cardiac examination we need a knowledge of the anatomy and physiology of the heart. The examination is divided into a standard examination and examination on indication. The standard examination comprises the inspection, palpation and auscultation of the heart. Examination on indication comprises additional palpation (quality of apex beat and thrills), percussion, additional auscultation (using the diaphragm or bell of the stethoscope in different positions) and assessment of central venous pressure. The section on the clinical significance of cardiac examination includes information on cardiac disorders that produce abnormal findings from physical examination. The following cardiac disorders are discussed: heart failure, myocardial infarction and ischaemia, heart valve defects, congenital heart defects and pulmonary hypertension, pericardial disease, arrhythmia (extrasystoles, atrial fibrillation, atrial flutter, atrioventricular nodal reentry tachycardia (AVNRT), atrial tachycardia) and conduction disorders (AV block and right and left bundle fascicular block).
E. L. van Veen, H. H. M. Al-Itejawi, M. Vanaeken, J. Iwema
17. The lungs and airways
The first step in pulmonary examination is taking a careful history. If the patient is suffering from shortness of breath, it may be worthwhile to gain information by observing them walking a short distance with you. Pulmonary examination then begins with the patient sitting on the examination table as comfortably as possible, with the upper body completely uncovered. The colour of the skin and tongue, the respiratory rate, pattern and effort can now be examined. Palpation is used to determine chest expansion and check for any vibration, tenderness and/or subcutaneous emphysema. Percussion will reveal any dullness (e.g. due to pleural fluid) or hyperresonant area (e.g. due to pneumothorax). This is followed by auscultation of the various parts of the lungs: abnormal breath sounds with or without adventitious sounds sounds, such as rhonchi, crackles and pleural rub, may provide clues to particular lung diseases. More and more pneumonologists are adding ultrasound scanning of the chest and lungs to their examinations: if the ultrasound technician is adequately skilled, this provides accurate detection of common causes of respiratory failure such as pneumonia, pleural effusion and pneumothorax.
G. Vonk Noordegraaf-Roseboom, L. M. M. J. Crombag, L. N. A. Willems
18. The breasts and axillae
Examination of the breasts can make a substantial contribution to the diagnosis of conditions including breast cancer. Both patients and physicians may find it embarrassing, but this can be reduced by carrying it out professionally and giving clear instructions to the patient. It will usually be carried out on indication, either because a patient feels a lump, or screening finds a suspicious lesion. It is important to discuss patients’ fears and concerns. Following a breast examination, the armpits will often be palpated, as any lymph node metastases are most likely to manifest themselves there. The differential diagnosis list for a palpable breast abnormality comprises cysts, fibroadenoma, lipoma, multinodular mastopathy, mastitis, abscess, haematoma and fat necrosis. Nipple disorders are also discussed in this chapter.
E. C. M. Zeestraten, A. J. E. van Breukelen

The abdomen

19. The anatomy of the abdomen and abdominal organs
Familiarity with the anatomy of the abdomen is required in order to be able to carry out an abdominal examination properly. The abdominal organs can be categorised in terms of location (e.g. intra-abdominal, retroperitoneal or infraperitoneal), and the patterns of symptoms will differ accordingly. The abdomen is divided into four quadrants or nine regions, to which the abnormalities found from physical examination can be assigned. We also discuss the anatomy of the liver, spleen, kidneys and bladder, the intestines, and the arterial and venous blood supply. The chapter concludes with a discussion of the anatomy of the groin, anus and rectum, but this is not exhaustive, given the purpose of this book. If you require in-depth information about the anatomy of the abdomen, we would refer you to anatomy textbooks.
L. L. F. G. Valke, M. J. T. Gerhardus, R. J. M. Claessen, K. Duitscher-Fransen, E. P. Moll van Charante
20. General examination of the abdomen
A general examination of the abdomen is carried out systematically in the following order: inspection, auscultation, percussion and palpation. The elements described in this chapter are part of a general abdominal examination; further examination or tests can be carried out as required. We consider the skin and abdominal wall, internal organs and blood vessels. Special attention is paid to the percussion and palpation of the liver and spleen.
M. J. T. Gerhardus, R. J. M. Claessen, L. L. F. G. Valke, K. Duitscher-Fransen, E. P. Moll van Charante
21. The abdominal examination on indication
This chapter describes the more specialist types of abdominal examination that are usually only carried out if a particular disorder or pathology of a specific organ is suspected. A suspicion of this kind may result from a general abdominal examination, possibly combined with other clinical data. We discuss the following examinations and their significance: the kidneys (e.g. structural abnormalities and pyelonephritis), the bladder (e.g. urinary retention), the gall bladder (e.g. cholecystitis or other bile duct pathology), ascites (e.g. liver pathology or malignancy), and acute abdomen (e.g. peritonitis, appendicitis, pancreatitis).
R. J. M. Claessen, L. L. F. G. Valke, M. J. T. Gerhardus, K. Duitscher-Fransen, E. P. Moll van Charante
22. The groin
Various intersecting structures are found in the groin, for example vascular structures, lymph nodes and vessels, tendons and muscles. This chapter focuses on inguinal hernias and their diagnosis. Examination of the blood vessels and lymph nodes is discussed in other chapters. The most common type of inguinal hernia is lateral inguinal hernia (also referred to as ‘indirect inguinal hernia’), followed by medial inguinal hernia (‘direct inguinal hernia’). Femoral hernia is the least common type. It is important to distinguish between reducible and non-reducible inguinal hernia, as the latter presents a higher risk of strangulation, which cuts off the blood supply to the content of the hernial sac (usually bowel) and can cause ischaemia. Inguinal hernia can be diagnosed from physical examination, if necessary supplemented by an ultrasound scan, if there is doubt as to the origin of the swelling.
L. L. F. G. Valke, M. J. T. Gerhardus, R. J. M. Claessen, K. Duitscher-Fransen, E. P. Moll van Charante
23. The anus and the rectum
Examination of the anus and rectum can be embarrassing for both patients and physicians. If it is carried out professionally, giving clear instructions to the patient, it can provide important information on disorders that manifest themselves in this region. It is important to have the patient adopt the correct position before starting the examination: this could be supine, lateral or knee-elbow position or standing. Begin by inspecting the anus and perianal region, followed by anal palpation and then rectal examination. The technique required to carry out this examination correctly is described in this chapter, followed by a description of the clinical significance of any abnormalities and the scientific value of anal and rectal examination.
L. L. F. G. Valke, R. J. M. Claessen, M. J. T. Gerhardus, K. Duitscher-Fransen, E. P. Moll van Charante
24. The male genitalia
Andrological examination involves intimate body parts, so these patients tend to be tense. Accordingly, the way in which the examination is conducted merits extra attention. Inspection involves looking at the development of secondary sexual characteristics, hygiene and abnormalities of the penis and scrotum, such as scars, warts, ulcers, redness, swelling and discharge. The penis should only be palpated on indication (if required). Palpation of the scrotum is used to check whether the vas deferens is complete and for scrotal swellings, which could be in the skin or intrascrotal (alongside or around the testes). When palpating the testes and epididymis, check them for symmetry, size, consistency, surface texture and the presence or absence of pain. The skin around the anus should be inspected during rectal examination. When palpating the prostate, assess it for size, symmetry, surface texture, the presence or absence of sulcus, pain, delineation and consistency. The discussion includes the following abnormalities of the penis: phimosis, balanitis, lichen sclerosis, hypospadias, meatal stenosis, condylomata acuminata, syphilis, genital herpes and Peyronie’s disease. Abnormalities of the scrotum can include testicular dysgenesis syndrome (TSD), testicular cancer, hydrocele, spermatocele, varicocele, testicular torsion, orchitis and epididymitis. Prostate abnormalities can be indicative of conditions like benign prostate enlargement, prostate cancer and prostatitis.
B. L. Ronkes, A. Meißner, K. E. Ebels
25. The female genitalia
This chapter describes the gynaecological examination. We first briefly consider the anatomy of the female genitalia, with special reference to the changes that the female genital tract undergoes during various life stages. We then describe the various elements of gynaecological examination – external inspection, speculum examination and bimanual examination – mentioning important points to consider when carrying them out. Attention should be paid to how you communicate with the patient, and you should treat them with respect. After describing the technique required for each particular skill, we discuss possible clinical findings and their significance. Various tests on indication (e.g. vaginal discharge and cervical smear tests) are also dealt with, and the role of ultrasound scanning in gynaecological consultations is briefly considered. The chapter concludes with a summary of the evidence available on gynaecological examination in the literature, and a summary of the entire examination.
E. Hageraats, A. P. Gijsen, S. F. Urbach

The peripheral circulation

26. The arterial and venous circulation
Narrowing, dilation, traumatic injury and abnormal interconnections in the peripheral vascular system (arteries and veins) can cause symptoms of ischaemia, aneurysm, bleeding or arteriovenous fistula. Circulation problems can occur anywhere in the body, but they frequently manifest in the lower extremities. Initial examination comprises inspection, palpation and auscultation, if necessary supplemented with a capillary refill test. We also discuss examination for some peripheral circulation disorders: chronic venous insufficiency, venous thrombosis, peripheral arterial disease, acute arterial occlusion, deep vein thrombosis, compartment syndrome, blue toe syndrome and diabetic foot. Arterial Doppler ultrasound to determine the ankle brachial index and Allen’s test are discussed under ‘Examination on indication’.
J. J. A. M. van den Dungen, I. Fourneau, P. M. Bloemendaal

The musculoskeletal system

27. Musculoskeletal examination
When examining the musculoskeletal system, it is important for the patient to be sufficiently unclothed, so that the connections between the joints and any left-right differences can be observed. There is no need to remove underwear. The examination should be carried out in the following order: inspection (including palpation), gait, passive movement assessment, isometric muscle tests, clinical palpation and any other tests indicated. The patient should be observed throughout the examination to determine the ranges of motion and any movement limitations. Make sure that you can always see the patient’s face while doing the physical examination. Any abnormalities found from physical examination should always be interpreted in light of the patient’s context (from history-taking). Physical examination findings will be more reliable if the findings from history-taking, inspection, movement assessment, specific tests and palpation combined are consistent with the diagnosis.
J. Damen, G. M. Rommers, M. W. J. L. Schmitz, C. J. Haven
28. The spine
Examination of the spine consists of examining the cervical, thoracic and lumbar spinal column. Make sure that the patient is sufficiently unclothed, so that the connections between the various parts can be observed. The examination should be carried out in the following order: inspection (with superficial palpation), movement assessment, clinical palpation and the specific tests. It is important to observe the patient for movement limitations and pain throughout the tests, to stabilise the trunk and use the correct hand positions for the various joints being examined. Any abnormalities found from physical examination should always be interpreted in light of the patient’s context (from history-taking). As an isolated abnormal test finding will often have little scientific value. Physical examination findings will more reliable if those from history-taking, inspection, movement assessment, palpation and the specific test combined are consistent with the diagnosis. Common abnormalities and problems that can be found include scoliosis, thoracic kyphosis, neck and back problems (e.g. lumbago and non-specific myalgia), and degenerative disorders, such as spondylosis, spondylarthrosis deformans and facet joint arthrosis.
G. M. Rommers, G. M. M. Winnubst, J. Damen, M. W. J. L. Schmitz, C. J. Haven
29. The upper extremities
Examination of the upper limbs comprises examination of the shoulders, elbows, hands and wrists. Make sure that the patient is sufficiently unclothed, so the connections between the joints and any left-right differences can be observed. The examination should be carried out in the following order: inspection, palpation and the specific tests. It is important to observe the patient for movement limitations and pain throughout the tests, to stabilise the trunk and to use the correct hand positions for the various joints being examined and the correct ranges of motion. Any abnormalities found from physical examination should always be interpreted in light of the patient’s context (from history-taking), as an isolated abnormal test finding will often have little scientific value. Physical examination findings will more reliable if those from history-taking, inspection, movement assessment, palpation and the specific test combined are consistent with the diagnosis.
J. Damen, G. M. Rommers, M. W. J. L. Schmitz, C. J. Haven
30. The lower limbs
Examination of the lower limbs comprises examination of the hips, knees, ankles and feet. Make sure that the patient is sufficiently unclothed, so that the connections between the joints and any left-right differences can be observed. There is no need to remove underwear. The examination should be carried out in the following order: movement assessment, isometric muscle tests, clinical palpation and any other tests indicated. The patient should be observed throughout the examination to determine the ranges of motion and any movement limitations, so make frequent eye contact with the patient. Also ask about pain when appropriate. It is important to carry out the tests correctly and to make sure you stabilise the trunk to enable you to make a correct assessment of such things as ranges of motion and stability. Any abnormalities found from physical examination should always be interpreted in light of the patient’s context (from history-taking). Physical examination findings will more reliable if those from history-taking, inspection, movement assessment, specific tests and palpation combined are consistent with the diagnosis.
G. M. Rommers, J. Damen, M. W. J. L. Schmitz, C. J. Haven

Neurological examination

31. The neurological examination
Observation of the patient during the consultation provides a good deal of useful information about the normal neurological function of the central and peripheral nervous system. A general neurological examination is comprehensive, covering the higher cerebral functions (e.g. consciousness, perception (gnosis) and spatial awareness, memory, judgment, moods and emotions, voice, speech and language and praxis), the cranial nerves, posture and gait, motor function, sensation, reflexes and coordination, and dysdiadochokinesia. Additional tests may also be carried out to assess consciousness, depending on the symptoms and the examination findings. Specific tests (e.g. meningeal irritation tests, radicular provocation tests and tests of the primitive reflexes) can also be carried out.
M. Steenis, V. J. J. Odekerken, M. M. A. Ketels, R. Dijcks

Mental state

32. The Mental State Examination (MSE)
A psychiatric diagnosis involves the systematic collection, categorisation, interpretation and communication of medical-psychological information. The mental state examination (MSE) is part of a ‘classifying diagnosis’, i.e. an assessment of mental functions as the basis for a structural diagnosis. A structural diagnosis includes not only the signs and symptoms but also how they developed, the patient’s subjective experience and the impact on activities of daily living, and biological, psychological and social factors (including stress). Mental functions are divided into ‘cognitive’, ‘affective’ and ‘conative’, i.e. ‘thought’, ‘feelings’ and ‘actions’ respectively. The aim of an MSE is to assess these mental functions, by listening to what the patient says, actively asking questions (exploration), observing how the patient says something and behaves, and being aware of the interaction between your own mental functions and the conversation (self-observation). Do not hesitate to tackle difficult subjects, e.g. suicidality or delusions (‘crazy ideas’). Remain empathetic and authentic while asking questions, and accept the patient as they are unconditionally.
M. J. Smeets, P. A. E. Domen

General physical examination in adults

33. General physical examination in adults
This chapter describes the physical examination, generally referred to as a ‘general internal examination’. We distinguish between the examinations that are always carried out and those only carried out on indication (as required). We describe the examination in a logical order that is most comfortable for patients. It starts with gaining a first impression, measuring data and vital signs, and then examining the patient from top to toe. The following examinations are described systematically in this order: general examination and first impression (including vital signs and inspection based on ACIDOT), head and neck examination (face, eyes and pupils, mouth and throat, lymph nodes and salivary glands, other neck structures), chest examination, examination of the abdomen and groin, and lastly examination of the limbs. Detailed descriptions of each examination can be found in the other chapters.
I. M. Jazet, M. H. J. van de Pol, H. J. Vermeulen

Special groups

34. Antenatal and postnatal women
This chapter sets out the essential elements of history-taking, physical examination and diagnostic tests during pregnancy and the postnatal period. The aim of a prenatal check-up is to detect any health risks that could be due to the pregnancy or that present a threat to it in good time. A vital part of care for a pregnant woman is history-taking: this provides the basis for a risk assessment and enables information to be provided to the mother about the impact of the pregnancy on her condition and vice versa. The physical examination and diagnostic tests (including ultrasound, cardiotocography and prenatal diagnosis) also provide information on the development and condition of the foetus. The main points to consider in the case of a post-natal woman are set out at the end of the chapter. Some common complications that can occur during pregnancy and the postnatal period that can potentially have an adverse impact on the health of the mother and/or child are discussed in relation to findings from physical examination.
F. B. M. Gan-Creijghton, I. Schipper, E. Hageraats
35. The newborn baby
All children in the Netherlands are routinely examined immediately after delivery by the person who supervised the birth. Examination of the ‘wet’ neonate involves assessing the newborn baby’s vitality (based on the Apgar score) and diagnosing any congenital abnormalities found. It is important, therefore, to examine the baby from top to toe following a fixed system. We also discuss the acutely sick infant, as the order of the examination and the specific points to watch out for will be substantially different. This chapter describes the complete physical examination, followed by the interpretation and potential significance of any abnormal findings.
A. Oren, E. Thys, J. M. Kerstjens
36. The child
The physical examination of children presents various challenges, as each age requires a different approach and a different communication style. Children need to be taken seriously and addressed on a level that is suitable for their age. Observation starts in the waiting room, with the aim of gaining a good impression of such things as motor and psychosocial development. The child’s situation or age will often determine the order in which the physical examination is conducted, and flexibility and humour can be extremely useful here. It is important to be familiar with the normal ranges of vital signs in children, and also the consequences of any abnormal results: respiratory insufficiency, for instance, is more likely to occur in children because of their build and more limited compensation mechanisms. Examination of the abdomen, heart, lungs and ear, nose and throat area is important in all children. Further investigation on indication may be necessary, such as a neurological evaluation or assessment of secondary sexual characteristics.
R. A. Doedens, A. Postma, L. J. W. M. Pierik, A. Kingma
37. Vulnerable elderly patients
Vulnerable elderly (geriatric) patients will usually be older than, and ‘different’ from adult patients. In addition to multimorbidity and polypharmacy, they will often present differently or atypically and under-report, and this affects their illnesses and how we conduct physical examinations. A comprehensive geriatric assessment (CGA) should normally be carried out on these patients. This chapter sets out what examinations and tests you should do, why, how, and some specific tests for cognition functions, physical activity and self-sufficiency.
H. H. M. Hegge, R. Franssen
Meer informatie
Physical Diagnostics
T.O.H. de Jongh MD
F.J. Jongen-Hermus MSc
J. Damen MD PhD
H.E.M. Daelmans MD PhD
R. Franssen MD PhD
I. de Klerk-van der Wiel MSc
A.D. Pieterse MD
B.J.J.W. Schouwenberg MD PhD
F. Schuring MD
Bohn Stafleu van Loghum
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