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A Practical Guide to Clinical Medicine

A comprehensive physical examination and clinical education site for medical students and other health care professionals

Web Site Design by Jan Thompson, Program Representative, UCSD School of Medicine.
Content and Photographs by Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California 92093-0611.
Send Comments to: Charlie Goldberg, M.D.

Introduction Breast Exam Write Ups
History of Present Illness Male Genital/Rectal Exam The Oral Presentation
The Rest of the History The Upper Extremities Outpatient Clinics
Review of Systems The Lower Extremities Inpatient Medicine
Vital Signs Musculo-Skeletal Exam Clinical Decision Making
The Eye Exam The Mental Status Exam Physical Exam Lecture Series
Head and Neck Exam The Neurological Exam A Few Thoughts
The Lung Exam Physical Exam Check Lists Commonly Used Abbreviations
Cardiovascular Exam Medical Links References
Exam of the Abdomen    

The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures. DaVinci's Anatomy Symbol

References

Introduction

Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees: A comparison of diagnostic proficiency. JAMA 1997; 278: 717-22.

Mangione S, Nieman LZ, Gracely E, Kaye D. The teaching and practice of cardiac auscultation during internal medicine and cardiology training: nationwide survey. Ann Intern Med 1993; 119: 47-54.

Nardone, Lucan LM, Palac DM. Physical examination: A revered skill under scrutiny. Southern Medical Journal 1988; 81: 770-73.

Sackett DL, Rennie D. The science of the art of the clinical examination. JAMA 1992; 267: 2650-52.

Sapira JD. Why perform a routine history and physical examination? Southern Medical Journal 1989; 82: 364-65.

Wiener S, Nathanson M. Physical examination: Frequently observed errors. JAMA 1976; 2: 852-55.

History of Present Illness

Avorn J, Everitt DE, Baker MW. The neglected medical history and therapeutic choices for abdominal pain: A nationwide study of 799 physicians and nurses. Arch Intern Med 1991; 151: 694-98.

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edition, Philadelphia; Lippincott 1999: 1-42.

Bingham J. On Being a Patient: A Complaint Against "Complaints." Ann Intern Med. 2003; 138: 73-74.

Hampton JR, Harrison, MJF, Mitchell JRA, Prichard JF, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. British Medical Journal 1975; 2: 486-89.

Oboler SK, LaForce M. The periodic physical examination in asymptomatic adults. Ann Intern Med 1989; 110: 214-26.

Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. West J Med 1992; 156: 163-65.

Rich EC, Crowson TW, Harris IB. The diagnostic value of the medical history: Perceptions of internal medicine physicians. Arch Intern Med 1987; 147: 1957-60.

Sandler G. The importance of the history in the medical clinic and the cost of unnecessary tests. American Heart Journal 1980; 100: 928-31.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 1-46.

Review of Systems

Anand SS, et al. Does this patient have deep vein thrombosis? JAMA 1998; 279 (14): 1094-9.

Anderson MR, et al. Evaluation of vaginal complaints. JAMA 2004; 291 (11): 1368-79.

Bastian L, et al. Is this patient peri-menopausal? JAMA 2003; 289 (7): 895-902.

Bent S, et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA 2002; 287 (20): 2701-10.

Bickley L. Bates' Guide to Physical Examination. 7th edition, Philadelphia; Lippincott Williams and Wilkins 1999: Review of Systems, 8-11.

Bradford J, et al. Blurred vision. NEJM 2000; 343 (8): 556-62.

Chunilal SD, et al. Does this patient have pulmonary embolism? JAMA 2003; 290 (21): 2849-58.

Cuker A, et al. A bloody mystery. NEJM 2009; 361 (19): 1887-94.

Degowin R, et al. Degowin's Diagnostic Examination. 7th edition. McGraw Hill 2000: Review of Systems, 29-31.

Detsky AS, et al. The rational clinical examination: Is this patient malnourished? JAMA 1994; 271 (1): 54-8.

Detsky ME, et al. Does this patient with headache have a migraine or need neuroimaging? JAMA 2006; 296 (10): 1274-83.

Deyo R, et al. Low back pain. NEJM 2001; 344 (5): 363-70.

Froehling DA, et al. The rational clinical examination: Does this dizzy patient have a serious form of vertigo? JAMA 1994; 271 (5): 385-8.

Goadsby P, et al. Migraine - Current understanding and treatment. NEJM 2002; 346 (4): 257-70.

Green P et al. Celiac disease. NEJM 2007; 357 (17): 1731-43.

Gross G. Review of Systems. Maine Medical Center, Dept of Internal Medicine. Nov 1989.

Hoffbrand BI. Away with the system review: a plea for parsimony. BMG 1989; 298: 817-9.

Holroyd-Leduc JM, et al. What type of urinary incontinence does this woman have? JAMA 2008; 299 (12): 1366-56.

Jacobs D. A 52 year-old suicidal man. JAMA 2000; 283: 2693-99.

Jager R, et al. Age related macular degeneration. NEJM 2008; 358(24): 2606-17.

Khan NA, et al. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA 2006; 295 (5): 536-46.

Klompas M. Does this patient have an acute thoracic aortic dissection? JAMA 2002; 287 (17): 2262-72.

Margaretten ME, et al. Does this adult patient have septic arthritis? JAMA 2007; 297 (13): 1478-88.

Metlay J, et al. Does this patient have community-acquired pneumonia? Diagnosisng pneumonia by history and physical examination. JAMA 1997; 278 (17): 1440-5.

Mitchell TL, et al. Yield of the screening review of systems: a study on a general medical service. JGIM 1992; 7 (4): 393-7

Panju A, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA 1998; 280 (14); 1256-63.

Rao G, et al. Does this patient have Parkinson disease? JAMA 2003; 289 (3); 347-53.

Schwenk T. Screening for depression in primary Care. JAMA 2000; 284 (11): 1379-80.

Schwenk T. Screening for depression in primary care: a disease in search of a test; JGIM 1996; 11: 437-9.

Sharpe M, wt al. ABC of psychological medicine. BMJ 2002; 325: 480-3.

Swartz MH. Swartz Textbook of Physical Diagnosis: History and Examination. 4th edition, WB Saunders 2002: Review of Systems, 28-30.

Silen W. Cope's early diagnosis of the acute abdomen. 17th edition. Oxford University Press 1987.

Trowbridge RL, et al. Does this patient have acute cholecystitis? JAMA 2003; 289 (1): 80-6.

Wagner J. Does this patient have appendicitis? JAMA 1996; 276 (19): 1589-94.

Wang CS, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA 2005; 294 (15) 1944-56.

Wells PS, et al. Does this patient have deep ein thrombosis? JAMA 2006; 295 (2): 199-207.

Whited JD, et al. The rational clinical examination: Does this patient have a mole or a melanoma? JAMA 1998; 279 (9): 696-701.

Williams J. Is this patient clinically depressed? JAMA 2002; 287 (9):1160-70.

Williams JW, et al. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA 1993; 270 (10): 1242-6.

Vital Signs

American Heat Association. Recommendations for human blood pressure determination by sphygmomanometers. American Heart Association Publication 1980.

Benowitz NL, Kuyt F, Jacob P. Influence of nicotine on cardiovascular and hormonal effects of cigarette smoking. Clin Pharmacol Ther 1984; 36: 74-81.

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edition, Philadelphia; Lippincott 1999: 292-99.

Caird FI, Andrew GR, Kennedy RD. Effect of posture on blood pressure in the elderly. British Heart Journal 1973; 35: 527-30.

Corley DA, Stefan AM, Wolf M, Cook F, Lee TH. Early indicators of prognosis in upper gastrointestinal hemorrhage. Am J Gastroenterology 1998; 93: 336-340.

Crenner CW. Introduction of the blood pressure cuff into U.S. medical practice: Technology and skilled practice. Ann Intern Med 1998; 128: 488-93.

Frohlich ED, Grim C, Labarthe DR, Maxwell MH, Perloff D, Weidman WH. Recommendations for human blood pressure determination by sphygmomanometers: Report of a special task force appointed by the steering committee, American Heart Association. Hypertension 1988; 11: 210a-221a.

Joint national committee on prevention, detection, and treatment of high blood pressure and the national high blood pressure education program coordinating committee. The sixth report of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure. Arch Intern Med 1997; 157: 2413-2443.

Kollef MH, O'Brien JD, Zuckerman GR, Shannon W. BLEED: A classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage. Crit Care Med 1997; 25: 1125-32.

Koziol-McLain J, Lowenstein SR, Fuller B. Orthostatic vital signs in emergency department patients. Ann Emerg Med 1991; 20: 606-10.

Londe S, Klitzner TS. Auscultatory blood pressure measurement - Effect of pressure on the head of the stethoscope. West J Med 1984; 141: 193-95.

Maxwell MH, Waks AU, Schroth PC, Karam M, Dornfeld LP. Error in blood-pressure measurement due to incorrect cuff size in obese patients. Lancet July 3, 1982; 33-35.

McGee S, Abernethy WB, Simerl DL. Is this patient hypovolemic? JAMA 1999; 281: 1022-29.

McGrady A, Higgins JT. Effect of repeated measurements of blood pressure on blood pressure in essential hypertension: Role of anxiety. J of Behavioral Medicine 1990; 13: 93-101.

O'Brien ET, O'Malley. ABC of blood pressure measurement: The patient. British Medical Journal October 13, 1979: 920-21.

O'Brien ET, O'Malley. ABC of blood pressure measurement: The sphygmomanometer. British Medical Journal October 6, 1979: 851-53.

O'Brien ET, O'Malley. ABC of blood pressure measurement: Technique. British Medical Journal October 20, 1979: 982-84.

Reeves RA. Does this patient have hypertension? How to measure blood pressure. JAMA 1995; 273: 1211-18.

Russell AE, Wing LMH, Smith SA, Aylward PE, McRitchie RJ, Hassam RM, West MJ, Chalmers JP. Optimal size of cuff bladder for indirect measurement of arterial pressure in adults. J of Hypertension 1989; 7: 607-613.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 139-53; 85-104.

Scherwitz LW, Evans LA, Hennrikus DJ, Vallbona C. Procedures and discrepancies of blood pressure measurements in two community health centers. Medical Care 1982; 20: 727-38.

Silverberg DS, Shemesh E, Iaina A. The unsupported arm: A cause of falsely raised blood pressure readings. British Medical Journal November 19, 1977; 1331.

Smith TDW, Clayton D. Individual variation between general practitioners in labeling of hypertension. British Medical Journal 1990; 300: 74-75.

Steinfeld L, Alexander H, Cohen ML. Updating sphygmomanometry. Am J of Cardiol 1974; 33: 107-10.

Viol GW, Goebel M, Lorenz GJ, Ing TS. Seating as a variable in clinical blood pressure measurement. American Heart Journal 1979; 98: 813-14.

Waaler HT. Specificity and sensitivity of blood pressure measurements. J of Epidemiology and Comm Health 1980; 34: 53-58.

Ward C, Kenny RA. Reproducibility of orthostatic hypotension in symptomatic elderly. Am J of Med 1996; 100: 418-22.

Webb CH. The measurement of blood pressure and its interpretation. Primary Care 1980; 7: 637-51.

The Eye Exam

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edition, Philadelphia; Lippincott 1999: 163-70, 184-95, 211-27.

Leibowitz HM. The red eye. NEJM 2000; 343: 345-51.

McGee S. Evidence bsed physical diagnsosis, 2nd ed. Chapter 19: The pupils. Saunders 2007: 209-241.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 139-53; 155-205.

Shingleton BJ, O'Donoghue. Blurred vision. NEJM 2000; 343: 556-62.

Shingleton BJ. Eye injuries. NEJM 1991;325: 408-13.

Vaughan D, Asbury T, Riordan-Eva P. General ophthalmology. 15th edition, Stamford; Appleton and Lange 1999.

Wu G. Ophthalmology for primary care. 1st edition, Philadelphia; W.B. Saunders Company 1997.

Head and Neck Exam

Bagai A, Thavendiranathan P, Detsky A. Does This Patient Have Hearing Impairment? JAMA 2006; 295: 416 - 428.

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edition, Philadelphia; Lippincott 1999: 163-244.

Brander A, Viikinkoski P, Tuuhea J, Voutilainene L, Kivisaari L. Clinical versus ultrasound examination of the thyroid gland in common clinical practice. J Clin Ultrasound 1992; 20: 37-42.

Ferrer R. Lymphadenopathy: Differential diagnosis and evaluation. American Family Physician 1998; 58: 1313-20.

Habermann TM, Steensma DP. Lymphadenopathy. Mayo Clin Proc 2000; 75: 723-32.

Jarlov AE, Hegedus L, Gjorup T, Hansen JM. Observer variation in the clinical assessment of the thyroid gland. Journal of Internal Medicine 1991; 229: 159-61.

Kennedy D. A 48-year old man with recurrent sinusitis. JAMA 2000; 283: 2143-2150.

Linet OI, Metzler C. Incidence of palpable cervical nodes in adults. Postgraduate Medicine 1977; 62: 210-13.

Pangalis GA, Vassilakopoulos TP, Boussiotis A, Fessas P. Clinical approach to lymphadenopathy. Seminars in Oncology 1993; 20: 570-82.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 139-53; 207-237.

Siminoski K. Does this patient have a goiter? JAMA 1995; 273: 813-17.

Slap GB, Brooks JSJ, Schwartz S. When to perform biopsies of enlarged peripheral lymph nodes in young patients. JAMA 1984; 252: 1321-26.

Williams JW, Simel DL. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA 1993; 279: 1242-46.

The Lung Exam

Acres JC, Kryger MH. Clinical significance of pulmonary function tests: Upper airway obstruction. Chest 1981; 80: 207-11.

Andrews JL, Badger TL. Lung sounds through the ages: From Hippocreates to Laennec to Osler. JAMA 1979; 241: 2625-30.

Badgett RG, Tanaka DJ, Hunt DK, Jelley MJ, Feinberg LE, Steiner JF, Petty TL. Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone? Am J of Med 1993; 94: 188-96.

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edition, Philadelphia; Lippincott, 1999: 245-75.

Forgacs P. The functional basis of pulmonary sounds. Chest 1978; 73: 399-405.

Forgacs P. Lung sounds. Brit J Dis Chest 1969; 63: 1-12.

Heckerling PS, Tape TG, Wigton RS, Hissong KK, Leikin JB, Ornato JP, Cameron JL, Racht EM. Clinical prediction rule for pulmonary infiltrates. Ann Intern Med 1990; 113: 664-70.

Holleman DR, Simel DL. Does the clinical examination predict airflow limitation? JAMA 1995; 273: 313-19.

King DK, Thompson T, Johnson DC. Wheezing on maximal forced exhalation in the diagnosis of atypical asthma: Lack of sensitivity and specificity. Ann Intern Med 1989; 110: 451-55.

Loudon R, Murphy RLH. Lung sounds. Am Rev Respir Dis 1984; 130: 663-73.

Mannino DM, Etzel RA, Flanders D. Do the medical history and physical examination predict low lung function? Arch Intern Med 1993; 153: 1892-97.

Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? JAMA 1997; 278: 1440-45.

Osmer JC, Cole BK. The stethoscope and roentgenogram in acute pneumonia. Southern Med J 1966; 59: 75-77.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 245-81.

Schapira JM, Schapira MM, Funahashi A, McAuliffe TL, Varkey B. The value of the forced expiratory time in the physical diagnosis of obstructive airways disease. JAMA 1993; 270: 731-36.

Singal BM, Hedges JR, Radack KL. Decision rules and clinical prediction of pneumonia: Evaluation of low-yield criteria. Ann Emerg Med 1989; 18: 13-20.

Spiter MA, Cook DG, Clarke SW. Reliability of eliciting physical signs in examination of the chest. Lancet April 16, 1988: 873-75.

Stubbing DG Mathur PN, Roberts RS, Campbell EJM. Some physical signs in patients with chronic airflow obstruction. Am Rev Respir Dis 1982; 125: 549-52.

Thacker RE, Kraman SS. The prevalence of auscultatory crackles in subjects without lung disease. Chest 1982; 6: 672-74.

Weinberger S. Principles of Pulmonary Medicine. 1st edition, Philadelphia; W.B. Saunders Company 1986.

West JB. Respiratory Physiology. 4th edition, Baltimore; Williams and Wilkins 1990.

West JB. Pulmonary Pathophysiology. 4th edition, Baltimore; Williams and Wilkins 1992.

Wilkins RL, Dexter JR, Murphy RLH, DelBono EA. Lung sound nomenclature survey. Chest 1990; 98: 886-89.

Cardiovascular Exam

Bladgett RG, Lucey CR, Mulrow CD. Can the clinical examination diagnose left-sided heart failure in adults? JAMA 1997; 277: 1712-19.

Bethell HJN, Nixon PG. Cardiovascular Exam in supine and left lateral positions. British Heart Journal 1973: 35: 902-7.

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edtion, Philadelphia; Lippincott, 1999: 277-332.

Braunwald E (editor). Heart Disease: A Textbook of Cardiovascular Medicine. 5th edition, Philadelphia; W.B. Saunders Co.: 15-52.

Carabello BA, Crawford FA. Valvular heart disease. NEJM 1997; 337: 32-41.

Chambers BR, Norris JW. Outcome in paients with asymptomatic neck bruits. NEJM 1986; 315: 860-65.

Choudhyr NK, Echells EE. Does this patient have aortic regurgitation? JAMA 1999; 281: 2231-38.

Chun PKD, Dunn BE. Clinical clue of severe aortic stenosis: Simultaneous palpation of the carotid and apical impulses. Arch Inern Med 1982; 142: 2284-88.

Conn DC, Cole JS. The cardiac apex impulse: Clinical and angiographic correlation. Ann Intern Med 1971; 75: 185-91.

Constant J. Bedside Cardiology. 4th edition, Boston; Little, Brown and Co.; 1993.

Cook DJ, Simel DL. Does this patient have abnormal central venous pressure? JAMA 1996; 275: 630-34.

Cooperman M, Martin EW, Evans WE. Significance of asymptomatic carotid bruits. Arch Surg 1978; 113: 1339-40.

Curtiss EI, Matthews RG, Shaver JA. Mechanism of normal splitting of the second heart sound. Circulation 1975; 51: 157-64.

Davison R, Cannon R. Estimation of central venous pressure by examination of jugular veins. American Heart Journal 1974; 87: 279-82.

Ducas J, Magder S, McGregor M. Validity of the hepatojugular reflux as a clinical test of congestive heart failure. American Journal of Cardiology 1983; 52: 1299-1303.

Eagle KA, Quertermous T, Singer DE, Mulley AG, Reder VA, Boucher C, Strauss HW, Thibault GE. Left ventricular ejection fraction: Physician estimates compared with gated blood pool scan measurements. Arch Intern Med 1988; 148: 882-85.

Eilern SD, Crawford MH, O'Rourke RA. Accuracy of precordial palpation for detecting increased left ventricular volume. Ann Intern Med 1983; 99: 628-30.

Eisenberg PR, Jaffe AS, Schuster DP. Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients. Critical Care Medicine 1984; 12: 549-53.

Etchells E, Bell C, Robb K. Does this patient have an abnormal systolic murmur? JAMA 1997; 277: 564-71.

Executive committee for the asymtpomatic carotid atherosclerosis study. Endarterectomry for asymptomatic carotid artery stenosis. JAMA 1995; 273: 1421-28.

Ghail JK, Kadakia S, Cooper R, Liao Y. Bedside diagnosis of preserved versus impaired left ventricular systolic function in heart failure. American Journal of Cardiology 1991; 67: 1002-06.

Harvey WP. Cardiac Pearls. Disease-a-Month 1994; Mosby: 43-112.

Heyman A, Wilkinson WE, Heyden S, Helms MJ, Bartel AG, Karp HR, Tyroloer HA, Hames CG. Risk of stroke in asymptomatic persons with cervical arterial bruits: A population study in Evans County, Georgia. NEJM 1980; 302: 838-41.

Hurst JW, Hopkins LC, Smith RB. Noises in the neck. NEJM 1980; 302: 362-62.

Lembro NJ, DellÍtalia LJ, Crawford MH, O'Rourke RA. Bedside diagnosis of systolic murmurs. NEJM 1988; 318: 1572-78.

Maisel A, Atwood E, Goldberger AL. Hepatojugular reflux: Useful in the bedside diagnosis of tricuspid regurgitation. Ann Int Med 1984; 101: 781-81.

Mattelman SJ, Hakki A, Iskandrian AS, Segal BL, Kane SA. Reliability of beside evaluation in determining left ventricular function: Correlation with left ventricular ejection fraction determined by radionuclide ventriculography. J Am Coll Cardiol 1983; 1 (2): 417-20.

Munro NC, McIntoh S, Lawson J, Morley C, Sutton R, Kenny RA. Incidence of complications after carotid sinus massage in older patients with syncope. J American Geriatric Soc 1994; 42: 1248-51.

Meyers DG, Sagar KB, Ingram RF, Paulsen WJ, Romhilt DW. Diagnosis of aortic insufficiency: Comparison of auscultation and m-mode echocardiography to angiography. Southern Medical Journal 1982; 75: 1192-94.

Nellen M, Gotsman MS, Vogelpoel L, Beck W, Schrire V. Effects of prompt squatting on the systolic murmur in idiopathic hypertrophic obstructive cardiomyopathy. Brtish Medical Journal 1967; 3: 140-43.

North American symtpomatic carotid endarterectomy trial collaborators. Beneficial effect of carotid endarterecomy in symptomatic patients with high-grade stenosis. NEJM 1991; 325: 445-53.

O'Rourke MF. The arterial pulse in health and disease. American Heart Journal 1971; 82: 687-702.

Rahko PS. Prevalence of regurgitant murmurs in patients with valvular regurgitation detected by doppler echocardiography. Ann Intern Med 1989; 111: 466-72.

Rosenblum R, Delman AJ. Valsalva's maneuver and the systolic murmur of hypertrophic subaortic stenosis: A bediside diagnostic test. American Journal of Cardiology 1965; 15:868-70.

Roederer GO, Langlois YE, Jager KA, Primozich BS, Beach KW, Phillips DJ, Strandness DE. The natural history of carotid arterial disease in asymptomatic patients with cervical bruits. Stroke 1984; 15: 605-13.

Roldan C, Shively BK, Crawford MH. Value of the cardiovascular physical examination for detecting valvular heart disease in asymptomatic subjects. American Journal of Cardiology 1996: 77: 1327-31.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 283-370.

Sauve JS, Laupacis A, Ostbye T, Feagan B, Sacett DL. Does this patient have a clinically important carotid bruit? JAMA 1993; 270: 2843-45.

Schlant RC (editor). The Heart, Arteries and Veins. 8th edition, New York; McGraw-Hill, Inc.; 229-51.

Stoelting RK. Evaluation of right atrial pressure. Anesthesiology 1973; 38: 291-94.

Van Ruiswyk J, Noble H, Sigmann. The natural history of carotid bruits in elderly persons. Ann Intern Med 1990; 112: 340-43.

Vongpatanasin W, Hillis LD, Lange A. Prosthetic heart valves. NEJM 1996; 335: 407-16.

Wang C, Fitzgerald J, Schulzer M, Mak E, Ayas N. Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? JAMA 2005; 294: 1944 - 1956.

Westman EC, Matchar DB, Samsa GP, Mulrow CD, Waugh RA, Feussner JF. Accuracy and reliability of apical s3 gallop detection. Journal of General Internal Medicine 1995; 455-57.

Wolf PA, Kannel WB, Sorlie P, McNamara P. Asymptomatic carotid bruit and risk of stroke: The Framingham study. JAMA 1981; 245: 1442-45.

Exam of the Abdomen

Arnell TD, de Virgilio C, Donayre C, Grant E, Baker JD, White R. Abdominal aortic aneurysm screening in elderly males with atherosclerosis: The value of physical exam. The American Surgeon 1996; 62: 861-64.

Barkun AN, Camus M, Green L, Meagher T, Coupal L, de Stempel , Grover S. The bedside assessment of splenic enlargement. The American Journal of Medicine 1991; 91: 512-18.

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edition, Philadelphia; Lippincott, 1999: 355-86.

Castell C. How big is the normal liver, indeed! Arch Intern Med 1979; 139: 968-9.

Castell DO. The spleen percussion sign: A useful diagnostic technique. Ann Intern Med 1967; 67: 1265-67.

Castell DO, O'Brien KD, Muench H, Chalmers TC. Estimation of liver size by percussion in normal individuals. Ann Intern Med 1969; 70: 1183-89.

Chervu A, Clagett P, Valentine J, Myers SI, Rossi PJ. Role of physical examination in detection of abdominal aortic aneurysms. Surgery 1995; 117: 454-57.

Cumings S, Papadakis M, Melnick J, Gooding GAW, Tierney LM. The predictive value of physical examinations for ascites. West J Med 1985; 142: 633-36.

Eippe DF, Gifford RW, Stewart BH, Alfidi RJ, McCormack LJ, Vidt DG. Abdominal bruits in renovascular hypertension. Am J of Cardioll 1976; 37: 48-52.

Ebaugh FG, McIntyre OR. Palpable spleens: Ten-year follow-up. Ann Intern Med 1979; 90: 130-31.

Fink HA, Lederle FA, Roth CS, Bowles C, Nelson DB, Haas MA. The accuracy of physical examination to detect abdominal aortic aneurysm. Arch Intern Med 2000; 160: 833-36.

Fuller GN, Hargreaves MR, King DM. Scratch test in clinical examination of liver. Lancet January 23, 1988; 181.

Goldberg BB, Clearfield HR, Goodman GA, Morales JO. Ultrasonic determination of ascites. Arch Intern Med 1973; 131: 217-20.

Grover SA, Barkun AN, Sackett DL. Does this patient have splenomegaly? JAMA 1993; 270: 2218-21.

Guarino JR. Auscultatory percussion to detect ascites. NEJM 1986; 315: 1555-56.

Julius S, Stewart BH. Diagnostic significance of abdominal murmurs. NEJM 1967; 276: 1175-78.

Kiev J, Eckhardt A, Kerstein MD. Reliability and accuracy of physical examination in detection of abdominal aortic aneurysms. Vascular Surgery 1997; 31: 143-46.

Lederle FA, Simel DL. Does this patient have abdominal aortic aneurysm? JAMA 1999; 281: 77-82.

Lederle FA, Walker JM, Reinke DB. Selective screening for abdominal aortic aneurysms with physical examination and ultrasound. Arch Intern Med 1988; 148: 1753-56.

McClouglin MJ, Colapinto RF, Hobbs BB. Abdominal bruits: Clinical and angiographic correlation. JAMA 1975; 232: 1238-42.

Naylor CD. Physical examination of the liver. JAMA 1994; 271: 1859-65.

Rivin AU. Abdominal vascular sounds. JAMA 1972; 221: 688-90.

Simon N, Franklin SS, Bleifer KH, Maxwell MH. Clinical characteristics of renovascular hypertension. JAMA 1972; 220: 1209-18.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 371-90.

Sapira JD, Williamson DL. How big is the normal liver? Arch Intern Med 1979; 139: 971-73.

Silen W. Cope's early diagnosis of the acute abdomen. 17th edition, New York; Oxford Press 1987.

Skrainka B, Stahlhut J, Fulbeck CL, Knight F, Holmes RA, Butt JH. Measuring liver span. J Clin Gastroenterol 1986; 8: 267-70.

Sullivan S, Krasner N, Williams R. The clinical estimation of liver size: A comparison of techniques and an analysis of the source of error. British Medical Journal 1976; 2: 1042-43.

Turnbull JM. Is listening for abdominal bruits useful in the evaluation of hypertension? JAMA 1995; 274: 1299-1301.

Wagner JM, McKinney P, Carpenter JL. Does this patient have appendicitis? JAMA 1996; 276: 1589-94.

Williams JW, Simel DL. Does this patient have ascites? JAMA 1992; 267: 2645-48.

The Breast Exam

Adams K. Lump detection in simulated human breasts. Perception and Psychophysicis 1976; 20: 163-7.

Baines C, Miller A, Bassett A. Physical examination. Its role as a single screening modality in the Canadian national breast screening study. Cancer 1989; 63: 1816-22.

Baines CJ, Miller AB. Mammography versus clinical examination of the breasts. J Natl Cancer Institute Monographs 1997; 22: 125-9. Baines CJ. Physical examination of the breasts in screening for breast cancer. J Gerontol 1992; 47: 63-7.

Barnes C. Breast palpation technique: what is the finer pad? J Chronic Disease 1987; 40: 361-2.

Barton M, Harris R, Fletcher S. Does this patient have berast cnacer?: The screening clinical berast examination: Should it be done? How? JAMA 1999; 282: 1270-80.

Bickley LS. Bates' Guide to Physical Exam and History Taking. 9th edition, Philadelphia; Lippincott 2007: 337-357 .

Bloom HS, Criswell E, Pennypacker H. . Major stimulus dimensions determining detection of simulated breast lesions. Perception and Psychophysiology 1982; 32: 251-60.

Campbell HS, Fletcher SW, Pilgrim CA, Morgan TM, Lin S. Improving physicians and nurses clinical breast examination: A randomized controlled trial. Am J Prev Med 1991; 7: 1-8.

Donegan W. Evaluation of a palpable breast mass. NEJM 1992; 327: 937-42.

Fletcher S, O'Malley M, Earp J, Morgan T, Lin S, Dengan D. How best to teach women breast self-examination: A randomized controlled trial. Ann Int Med 1990; 112: 772-9.

Gulay H, Bora S. Management of nipple discharge. J Am Coll Surg 1994; 178: 471-4.

Hall D, Goldstein M, Stein G. Progress in manual breast examination. Cancer 1977; 40: 364-70.

Hall D, Adams C, Stein G, Stephenson H, Goldstein M. Improved detection of human breast lesions following experimental training. Cancer 1980; 46: 408-14.

Kerlikowske K, Simth-Bindman R, Ljung B, Grady D. Evaluation of abnormal mammography results and palpable breast abnormalities. Ann Intern Med 2003; 139: 274-84.

Love S, Gelman R, Silen W. Sounding board. Fibrocystic "disease of the breast - a nondisease? NEJM 1982; 307: 1010-4.

Mahoney L, Csima A. Efficiency of palpation in clinical detection of breast cancer. Can Med Assoc J 1982; 127: 729-30.

McDermott M, Dolan N, Huang J, Reifler D, Rademaker A. Lump detection is enhanced in silicone breast models stimulating postmenopausal breast tissue. JGen Intern Med 1996; 11: 112-4.

Mushlin A. Diagnostic tests in breast cancer. Clinical strategies based on diagnostic possibilities. Ann Int Med 1985; 103: 79-85.

Pilgrim C, Lannon C, Harris R, Cogburn W, Fletcher S. Improving clinical breast examination training in a medical school: A randomized trial. J of Gen Int Med 1993; 8: 685-8.

Sanders K, Pilgrim C, Pennypacker H. Increased proficiency of search in breast self exam. Cancer 1986; 58: 2531-7.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 239-43.

Screening for breast cancer; Summary of recomendations. U.S. Preventative Services Task Force (USPSTF). 2002. http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm

Stephenson HS, Adams CK, Hall DC, Pennypacker HS. Effects of certain training parameters on detection of simulated breast cancer. Journal of Behavioral Medicine 1979; 2: 239-50.

Winchester D. Physical examination of the breast. Cancer 1992; 69: 1947-9.

Male Genital/Rectal Exam

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edtion, Philadelphia; Lippincott, 1999: 387-403; 449-59.

Dixon JM, Elton RA, Rainey JB, Macleod DAD. Rectal examination in patients with pain in the right lower quadrant of the abdomen. British Medical Journal 1991; 302: 386-88.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 391-98, 411-14.

Wantz GE. A 65 year old man with an inguinal hernia. JAMA 1997; 277: 663-69.

The Upper Extremities

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edtion, Philadelphia; Lippincott, 1999: 461-68.

Dorrington KL. Skin turgor: Do we understand the clinical sign? Lancet January 31, 1981; 264-65.

Myers KA, Farquhar DRE. Does This Patient Have Clubbing? The Rational Clinical Examination. JAMA 2001; 286: 341-347.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 435-42.

Schriger DL, Baraff LJ. Capillary refill - Is it a useful predictor of hypovolemic states? Ann Emerg Med 1991; 20: 601-605.

Schriger DL, Baraff L. Defining normal capillary refill: Variation with age, sex and temperature. Ann Emerg Med 1988; 17: 932-35.

Shneerson JM. Digital clubbing and hypertrophic osteoarthropathy: The underlying mechanisms. Br J Dis Chest 1981; 75: 113-25.

The Lower Extremities

Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS. Does this patient have deep vein thrombosis? JAMA 1998; 279: 1094-99.

Barnes RW, Wu KK, Hoak JC. Fallibility of the clinical diagnosis of venous thrombosis. JAMA 1975; 234: 605-07.

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th Edtion, Philadelphia; Lippincott, 1999: 461-82.

Blankfield RP, Findelhor RS, Alexander JJ, Flocke SA, Maiocco J, Goodwin M, Zyzanski SJ. Etiology and diagnosis of bilateral leg edema in primary care. American Journal of Medicine 1998; 105: 192-97.

Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. NEJM 1994; 331: 854-60.

Cymet TC, Weisman DS. Lower leg ulcers. Hospital Physician July, 1997; 30-41.

Haeger K. Problems of acute deep venous thrombosis: The interpretation of signs and symptoms. Angiology 1969; 20: 219-223.

Hirsh J, Hull RD, Raskob GE. Clinical features and diagnosis of venous thrombosis. J Am Coll Cardiol 1986; 8: 114B-127B.

Loscalzo J (editor). Vascular Medicine: A textbook of vascular biology and diseases. 1st edition, Boston; Little, Brown and Compay 1992: 401-18.

Merli GJ, Spandorfer J. The outpatient with unilateral leg swelling. Medical clinics of North America 1995; 79: 435-47.

Nelzen O, Bergqvist D, Lindhagen A. Venous and non-venous ulcers: Clinical history and appearance in a population study. British Journal of Surgery 1995; 81: 182-87.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 442-49.

Sumpio BE. Foot ulcers. NEJM 2000; 343: 787-92.

Vaughan BF. CT of swollen legs. Clinical Radiology 1990; 41: 24-30.

Wells PS, Hirsh J, Andeson DR, Lensing AWA, Foster G, Kearon C, Weitz J, D'Ovidio, Cogo A, Prandoni P, Girolami A, Ginsberg JS. Accuracy of clinical assessment of deep-vein thrombosis. Lancet 1995; 345: 1326-30.

The Mental Status Exam

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edtion, Philadelphia; Lippincott, 1999: 107-27.

Froehlich TE, Robison JT, Inouye SK. Screening for dementia in the outpatient setting: The time and change test. J American Geriatrics Soc 1998; 46: 1506-11.

Hirschfeld RMA, Russell JM. Assessment and treatment of suicidal patients. NEJM 1997; 337: 910-15.

Lipowski, ZJ. Delirium (acute confusional states). JAMA 1987; 258: 1789-92.

Lipowski ZJ. Delirium in the elderly patient. NEJM 1989; 320: 578-82.

Small SM. Outline for psychiatric examination: 6-21.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 516-22.

Musculoskeletal Exam

Adkins S, Figler R. Hip pain in athletes. American Family Physician 2000; 61: 2109-20.

Anto C, Aradhya P. Clinical diagnosis of peripheral nerve compression in the upper extremity. Orthopedic Clinics of North America 1996; 27: 227-236.

Baker D, Schumacher H. Acute monoarthritis. NEJM 1993; 329: 1013-20.

Bernstein J, Ivins D. Impingement syndrome: differential diagnosis and treatment strategies. Hospital Medicine 1999 (Oct): 24-29.

Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edition, Philadelphia; Lippincott 1999: 483-5532.

Boyd R. Evaluation of back pain. Primary Care Medicine (Goroll A, Editor), 3rd Edition, Philadelphia; Lippincott 1995: 742-51.

Burkhart S. A 26-year-old woman with shoulder pain. JAMA 2000; 284: 1559-67.

Campbell CS. Gamekeeper's Thumb. The Journal of Bone and Joint Surgery1955; 37B: 148-49.

Canale TS. Campbell's Operative Orthopaedics 10th Ed., Philadelphia; Mosby: 2180-2211.

Cardone D, Tallia A. Diagnostic and therapeutic injection of the elbow region. American Family Physician 2002; 66: 2097-100.

Carragee E. Persistent low back pain. NEJM 2005; 352: 1891-98.

Chapman MW. Chapman's Orthopaedic Surgery 3rd Ed., Philadelphia; Lippincott: 2247-2265.

Chumbley E, O'Connor F, Nirschl R. Evaluation of overuse elbow injuries. American Family Physician 2000; 61: 691-702.

Colman W, Strauch R. Physical examination of the elbow. Orthopedic Clinics of North America 1999; 30: 15-20.

Daniels J, Zook E, Lynch J. Hand and wrist injuries: Part I. Non-emergent evaluation. American Family Physician 2004; 69: 1941-48.

Daniels J, Zook E, Lynch J. Hand and wrist injuries: Part II. Emergent evaluation. American Family Physician 2004; 69: 1949-56.

Deyo R, Rainville J, Kent D. What can the history and physical examination tell us about low back pain? JAMA 1992; 268: 760-5.

Dickey P. Surgical management of disc disease of the lumbar spine. Resident and Staff Physician 1997; 43: 41-50.

El-Gabalawy HS, Duray P, Goldbach-Mansky R. Evaluating patients with arthritis of recent onset. JAMA 2000; 284: 2368-73.

El-Khoury G, Renfrew D. Percutaneous procedures for the diagnosis and treatment of lower back pain: Diskography, facet-joint injection, and epidural injection. American Journal of Rheumatology 1991; 157: 685-91.

Frymoyer J. Back pain and sciatica. NEJM 1988; 318: 291-300.

Felson D; Osteoarthritis of the knee. NEJM 2006 354: 841-8.

Garfin S, Herkowitz H, Mirkovic S. Spinal stenosis. The Journal of Bone and Joint Surgery 1999; 81A: 572-86.

Jackson JL, O'Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Annals of Int Med 2003; 139: 575-99.

Lonner JH. A 57-year-old man with osteoarthritis of the knee. JAMA 2003; 289: 1016-25.

Luime JJ, Verhagen AP, Miedema HS. Does this patient have an instability of the shoulder or a labrum lesion? JAMA 2004; 292:1989-99.

Netter FH. Atlas of Human Anatomy, Summit, NJ; Ciba-Geigy Corporation 1989: 395-402, 476-80.

Nicholas JA. The upper extremity in sports medicine 2nd Ed, Philadelphia; Mosby 1995: 23-76.

Rectenwald, J. Stener lesion. E-Medicine 2005 http://www.emedicine.com/orthoped/topic313.htm.

Sapira JD. The Art and Science of Bedside Diagnosis. 1st edition, Baltimore; Williams and Wilkins 1990: 415-33.

Simon RR, Koenigsknecht SJ. Emergency Orthopedics, The Extremities, 3rd Ed, Stamford CT; Appleton and Lange 1996: 386-410, 437-60.

Skolnick AA. For some injuries, it's all in the name. JAMA 1998; 279: 572-73.

Smith CC. Evaluating the painful knee: A hands-on approach to acute ligamentous and meniscal injuries. Advanced Studies In Medicine 2004; 4: 362-69.

Snider RK. Essential of muscoskeletal care, 1st Ed. American Academy of Orthopedics 1997: 75-81, 311-9.

Solomon DH, Simel DL, Bates DW. Does this patient have a torn meniscus or ligament of the knee? JAMA 2001; 286: 1610-20.

Spiegel TM, Crues JV. The painful Shoulder: Diagnosis and treatment. Primary Care 1988; 15: 709-24.

Stener B. Displacement of the ruptured ulnar collateral ligament of the metarcarpo-phalangeal joint of the thumb. Journal of Bone and Joint Surgery 1962; 44b: 869-79.

Woodward TW, Best TM. The painful shoulder: Part I clinical evaluation. Americal Family Physician 2000; 61: 3079-88.

Sandler G. The importance of the history in the medical clinic and the cost of unnecessary tests. American Heart Journal 1980; 100: 928-31.

Neurological Exam

Bickerstaff ER. Neurological Exam in Clinical Practice. 4th edition, London; Blackwell Scientific Publications 1980.

Bickley LS. Bates' Guide to Physical Examination and History Taking. 7th edition, Philadelphia; Lippincott 1999.

Braunwalk E, Fauci A. Harrison's Principles of Internal Medicine. 15th edition, San Francisco; McGraw Hill 2001: 111-163, 2369-2441.

Caputo GM, Cavanagh PR. Assessment and management of foot disease in patients with diabetes. NEJM 1994; 331: 854-60.

Chiles BW, Cooper PR. Acute spinal injury. NEJM 1996; 334: 514-20.

Clark CM, Lee A. Prevention and treatment of the complications of diabetes mellitus. NEJM 1995; 332: 1210-17.

Cornbluth D. Peripheral neuropathy. NEJM 1982; 307: 1457.

D'Arcy C, McGee S.The Rational Clinical Examination: Does This Patient Have Carpal Tunnel Syndrome? JAMA 2000; 283: 3110-3117.

Dawson DM. Current concepts: Entrapment neuropathies of the upper extremities. NEJM 1993; 329: 2013-18.

Deyo R, Weinstein J. Low back pain. NEJM 2005; 344: 363-70.

Dyck PJ. Current concepts in nuerology. The causes, classification and treatment of peripheral neuropathy. NEJM 1982; 307: 283-86.

Furman JM, Cass SP. Primary care: Benign paroxysmal positional vertigo. NEJM 1999; 341: 1590-96.

Glick TH. Neurologic Skills: Examination and Diagnosis. Boston; Blackwell Scientific Publications 1993.

Gorson KC. Case 9-2001 - A 64 year old woman with peripheral neurophathy, paraproteinemia and lymphadenopathy. NEJM 2001; 344: 917-23.

Haerer AF. Dejong's: The Neurologic Examination. 5th Edition, New York; J B Lippincott; 1992.

Hotson JR, Baloh RW. Acute vestibular syndrome. NEJM 1998; 339: 680-85.

Katz JN, Simmons BP. Carpal tunnel syndrome. NEJM 2005; 346: 1807-11.

Lange AE, Lozano AM. Parkinson's disease - First of two parts. NEJM 1998; 339: 1044-53.

Lessell S. Optic neuropathies. NEJM 1978; 299: 533-36.

Louis ED. Essential tremor. NEJM 2001; 345: 887-91.

Mancall E. Alpers and Mancall's Essentials of the Neurologic Examination. edition 2, Philadelphia; FA Davis Co; 1981.

Nathan DM. Medical progress: Long term complications of diabetes mellitus. NEJM 1993; 328: 1676-85.

Clinical Decision Making

Kassirer JP. Diagnostic Reasoning. Ann Intern Med 1989; 110: 893-900.

Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine: How to Practice and Teach EBM. 1st edition, Edinburgh; Churchill Livingstone 1998.

Wernick R, Coyle C. Systemic lupus erythematosus: A streamlined, rational approach to diagnosis. Hospital Medicine April 1999; 16-22.

Bowen J. Educational strategies to promote clinical diagnostic reasoning. NEJM 2006; 355 (21): 2217-25.

A Few Thoughts

Gawande, Atul. When Doctors Make Mistakes. New Yorker Magazine; February 7, 1999: 40-55.

Diagnosis. JAMA 1901; 37: 1118 (reprinted in JAMA 2001; 286: 1944).

Verrees, Meg. Touch Me. JAMA 1996; 276: 1285-86.

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