PATIENT ASSESSMENT IN

PHARMACY PRACTICE

RHONDA M. JONES, Pharm.D.

Associate Professor and Coordinator, Professional Experience Program

Department of Pharmacy Practice

School of Pharmacy and Health Professions

Creighton University

Omaha, Nebraska

RAYLENE M. ROSPOND, Pharm.D., BCPS

Associate Dean and Chair

Department of Pharmacy Practice

College of Pharmacy and Health Sciences

Drake University

Des Moines, Iowa

Part OneOverview of Patient Assessment

Patient Assessment and thePharmaceutical Care Process 2Rhonda M. Jones

HISTORY AND EVOLUTION OFPHARMACEUTICAL CARE 2

PHARMACEUTICAL CARE 3

PHARMACEUTICAL CARE AND PATIENTASSESSMENT 4

DOCUMENTATION 5

SOAP Note 5Problem-Oriented Note 6Example 8

OPPORTUNITIES FOR PATIENTASSESSMENT 6

Self-Assessment Questions 8Critical Thinking Question 8

Bibliography 8

Cultural Considerations in PatientAssessment 9Rhonda M. Jones, Matin Royeen, and Jeffrey L. Crabtree

WHAT IS CULTURE? 10

Characteristics of Culture 10Ethnocentrism, Prejudice, and

Stereotypes 10CULTURAL VARIABLES THAT AFFECT PATIENT

ASSESSMENT 13

Differing Views of Health and Illness 13Biomedical 13Naturalistic 13Magico-Religious 14

Family Relationships 14Communication 15

Verbal 15Nonverbal 16Expression of Symptoms 16

HEALTH-RELATED BELIEFS OF SELECTEDGROUPS 17

European Americans 17African Americans 17Arab Americans 18Asian Americans 18Hispanic Americans 18Native Americans 18

Americans in Poverty 19Socioeconomic Status 19Accessibility 19

RECOMMENDATIONS TO ENHANCECULTURAL SENSITIVITY 19

Self-Assessment Questions 20Critical Thinking Question 20

Bibliography 20

3 Health and Medication History 21Rhonda M. Jones

BASIC PATIENT INTERVIEWING SKILLS 21

Environment 21Opening Statements 22Types of Questions 22

Open-Ended Questions 22Closed-Ended Questions 22

Verification of Patient Information 22Clarification 23Reflection 23Empathy 23Facilitation 23Silence 23Summary 23

Nonverbal Communication 23Distance 23Body Posture 24Eye Contact 24Facial Expression 24Gestures 24

Closing Statements 24Common Errors of Patient

Interviewing 24Changing the Subject 24Giving Advice 24Providing False Reassurance 25Asking Leading or Biased Questions 25Using Professional Terminology 25

HEALTH HISTORY 25

Patient Demographics 25Chief Complaint 25History of Present Illness 25Past Medical History 26Family History 26Social History 26Review of Systems 26

MEDICATION HISTORY 27

Current Prescription Medications 27Current Nonprescription Medications 27Past Prescription and Nonprescription

Medications 28Allergies 28

CONTENTS

Adverse Drug Reactions 28Medication Compliance 28Documentation of the Medication

History 28SPECIAL CONSIDERATIONS 30

Pediatric Patients 30Geriatric Patients 30

Self-Assessment Questions 30

Critical Thinking Questions 30

Bibliography 30

Principles and Methods of the BasicPhysical Examination 31Jean DeMartinis

BASIC PRINCIPLES OF THE EXAMINATION 31

METHODS OF ASSESSMENT 32

Inspection 32Palpation 32Percussion 33Auscultation 35

PREPARING FOR THE EXAMINATION 36Gathering the Equipment 36Preparing the Setting 37Ensuring the Patient's Safety 38

Standard Precautions 38Latex Allergy 38

THE EXAMINATION 38

Tips for the Novice Examiner 38Sequence of and Positioning for the

Examination 39Performing a Comprehensive

Examination 39SPECIAL CONSIDERATIONS 41

Pediatric Patients 41Geriatric Patients 41Pregnant Patients 42

Self-Assessment Questions 42

Critical Thinking Question 42

Bibliography 42

General Assessment and Vital Signs 43Rhonda M. Jones

PHYSICAL APPEARANCE, BEHAVIOR, ANDMOBILITY 43

Age 43Skin Color 43Facial Features 44Level of Consciousness 44Signs of Acute Stress 44Nutrition 44Body Structure 44Dress and Grooming 44

Behavior 44Mobility -H

PHYSICAL PARAMETERS -o

Height nWeight -nVital Signs -t5

temperature *(SOral Route ••""Rectal Route 4 "A/i l lar, Route •("*T.mpanir Route -4"

Pulse 48Respiratory Rate 48Blood Pressure l\k)

Methods of Measurement •(')Classification of Measurement 5 ICommon Errors of Measurement 51Factors Affecting Blood Pressure S3

SPECIAL CONSIDERATIONS M

Pediatric Patients 53Temperature 53Pulse 53Respiratory Rate 53Blood Pressure 53

Geriatric Patients 58Pregnant Patients 59

Self-Assessment Questions 60Critical Thinl-ing Questions (>()

Bibliography 60

6 Nutritional Assessment 62Raylene M. Rospnnd

NUTRITIONAL REQUIREMENTS 62

Energy 62Protein 63Fluid 63Micronutrients 63

PATHOLOGY OVERVIEW 63Protein-Calorie Malnutrition 64

Marasmus 64Kwaskiorkor 65Mixed Marasmus-Kwashiorkor 65Obesity 65Anorexia Nervosa and Bulimia Nervosa 66

Single-Nutrient Deficiencies 66Underlying Pathology with Nutritional

Effects 66Special Considerations 66

Pediatric Patients 66Geriatric Patients 67

Pregnant Patients 70

SYSTEM ASSESSMENT 70

Subjective Information 71Quantitative Dietary Assessment 72Qualitative Dietary Assessment 73

Contents

Objective Information 73Physical Examination 73Anthropometrical Measurements 73

Weight 73Height 74Body Mass Index 74Skinfold Thickness 74

Laboratory Measures 76Protein Status 77

Hematological Indices 77Iron Status 78Mineral Status 78Vitamin Status 78Lipid Status 79

Indices of Immune Function 80Special Considerations 81

Pediatric Patients 81Geriatric Patients 82Pregnant Patients 82

Self-Assessment Questions 83

Critical Thinking Questions 83Bibliography 83

Pain Assessment 85Raylene M. Rospond

ANATOMY AND PHYSIOLOGY OVERVIEW 85

Peripheral Pain System 85Nociceptors 85Pain Fibers 85

Ascending Pain Pathways 86Spinothalamic Tract 86Spinoreticular Tract 87

Descending Pain Pathways 87Pain-Mediating Substances 87

Pain-Producing Substances 87Pain-Mitigating Substances 88

Special Considerations 88Pediatric Patients 88

Geriatric Patients 88

PATHOLOGY OVERVIEW 88Acute Pain Syndromes 88

Somatic Pain 88Superficial Somatic Pain 88Deep Somatic Pain 88

Visceral Pain 88Treatment 89

Chronic Pain Syndromes 89Cancer Pain 89Nonmalignant Pain 89

Neuropathic Pain 89Musculoskeletal Pain 89

Treatment 89

SYSTEM ASSESSMENT 89

Subjective Information 89Pain Interview 90Pain Assessment Lnstruments 90

Single-Dimension Instruments 90Multidimensional Instruments 91

Objective Information 94Behavioral Observations 94Physiological Indicators 94

Special Considerations 94Pediatric Patients 94

Subjective Assessment 96Objective Assessment 96

Geriatric Patients 96Subjective Assessment 97Objective Assessment 97Self-Assessment Questions 98Critical Thinking Questions 98

Bibliography 99

Part TwoAssessment of Body Systems

8 Skin, Hair, and Nails 102Edward M. Simone LL

ANATOMY AND PHYSIOLOGY OVERVIEW 102

Skin 102Hair 104Nails 104Special Considerations 105

Pediatric Patients 105Geriatric Patients 105Pregnant Patients 105

PATHOLOGY OVERVIEW 105Skin 105

Inflammatory Conditions 105Contact Dermatitis 105Acne 107Eczema 108Diaper Rash 108

Infectious Conditions 108Measles 108Chickenpox 109Impetigo 109Fungal Infections 109

Adverse Cutaneous Drug Reactions 111Drug-Induced Urticaria, Angioedema,

and Anaphylaxis 111

Exanthematous Drug Eruption 111

Fixed Drug Eruption 112

Stevens-Johnson Syndrome 113

Drug-Induced Photosensitivity 113

CONTENTS

Infestations 113Scabies 113Pediculosis 114

Skin Cancer 114Hair 115

Infectious Folliculitis 115Furuncles and Carbuncles 116Alopecia 116

Nails 116SYSTEM ASSESSMENT 117

Subjective Information 117Skin Characteristics 117Pruritus 118Tenderness/Pain 118Additional Symptoms 118

Objective Information 118Physical Assessment 118Laboratory and Diagnostic Tests 119

Special Considerations 119Pediatric Patients 119Geriatric Patients 119Pregnant Patients 120

APPLICATION TO PATIENT SYMPTOMS 120

Rash 120Case Study 120

Self-Assessment Questions 123Critical Thinking Questions 123

Folliculitis 123Case Study 123

Self-Assessment Questions 126Critical Thinking Questions 126

Nail Infection 126Case Study 126

Self-Assessment Question 128Critical Thinking Question 128

Bibliography 128

Eyes and Ears 129Raylene M. Rospond

ANATOMY AND PHYSIOLOGY OVERVIEW 129

The Eye 129Layers of the Eye 129Chambers of the Eye 130Accessory Structures of the Eye 130Visual Fields and Pathways 131Visual Reflexes 131Extraocular Movements 132

The Ear 132External Ear 132Middle Ear 133Inner Ear 133

Special Considerations 134Pediatric Patients 134Geriatric Patients 134Pregnant Patients 135

PATHOLOGY OVERVIEW 135

The Eye 135Conjunctivitis 135Glaucoma 136

The Ear 137Otitis Media 137O tit is Externa 138

SYSTEM ASSESSMENT 138

Subjective Information 139The Eye 139The Ear 140

Objective Information 141Physical Assessment 141

The Eye 141The Ear 145

Laboratory and Diagnostic Tests 146Special Considerations 148

Pediatric Patients 148Geriatric Patients 148Pregnant Patients 149

APPLICATION TO PATIENT SYMPTOMS 149Red Eye 149

Case Study 150

Self-Assessment Questions 151Critical Thinking Question 152

Ear Pain 153Case Study 153

Self-Assessment Questions 156Critical Thinking Questions 156

Bibliography 156

10 Head and Neck 157Raylene M. Rospond and Michele Faulkner

ANATOMY AND PHYSIOLOGY OVERVIEW 157

Skull 157Muscles of the Neck 158Structures of the Head and Neck 158

Nose 158Paranasal Sinuses 159Mouth 159Pharynx 159Lymph Nodes 160

Special Considerations 162Pediatric Patients 162Geriatric Patients 162

Pregnant Patients 162

PATHOLOGY OVERVIEW 162

Headache 162Tension Headaches 162Migraine Headaches 162Cluster Headaches 163

Sinusitis 163Allergic Rhinitis 163Gingivitis 164Pharyngitis 164

Contents

I I

SYSTEM ASSESSMENT 165

Subjective Information 165Headache Pain 165Facial Pain 166Rhinorrhea 166Bleeding Gums 167Sore Throat 167Swollen Lymph Nodes 168

Objective Information 168Physical Assessment 168

Skull, Scalp, and Face 168Nose 169Sinuses 170Mouth and Pharynx 171Neck and Lymph Nodes 172

Laboratory and Diagnostic Tests 173Special Considerations 173

Pediatric Patients 173Geriatric Patients 174Pregnant Patients 174

APPLICATION TO PATIENT SYMPTOMS 175Headache Pain 175

Case Study 175Self-Assessment Questions 176Critical Thinking Questions 176

Facial Pain 178Case Study 178

Self-Assessment Questions 179Critical Thinking Questions 179

Sore Throat 181Case Study 181

Self-Assessment Questions 183Critical Thinking Questions 183

Bibliography 185

Respiratory System 186Rhonda M. Jones

ANATOMY AND PHYSIOLOGY OVERVIEW 186

Surface Landmarks 187Anterior Thoracic Landmarks 187Posterior Thoracic Landmarks 187Reference Lines 188

Trachea and Bronchial Tree 188Lungs 188Respiration 188Special Considerations 189

Pediatric Patients 189Geriatric Patients 189Pregnant Patients 189

PATHOLOGY OVERVIEW 190

Asthma 190Chronic Obstructive Pulmonary

Disease 193Pneumonia 196

SYSTEM ASSESSMENT 196

Subjective Information 196Cough 196Sputum 197Dyspnea 197Wheezing 197Chest Pain with Breathing 197

Objective Information 197Physical Assessmen t 197Laboratory and Diagnostic Tests 201

Special Considerations 202Pediatric Patients 202Geriatric Patients 202Pregnant Patients 203

APPLICATION TO PATIENT SYMPTOMS 203Dyspnea 203

Case Study 203Self-Assessment Questions 205Critical Thinking Questions 205

Wheezing 206Case Study 207

Self-Assessment Questions 208Critical Thinking Questons 208

Cough 209Case Study 209

Self-Assessment Quest ions 210

Critical Thinking Quest ions 210

Bibliography 212

12 Cardiovascular Sys tem 213Rhonda M. Jones and Maryann Z. Skrabal

ANATOMY AND PHYSIOLOGY OVERVIEW 213

Circulatory System 213Heart 213

Conduction System 214Cardiac cycle 215Heart Sounds 217

Normal Heart Sounds 217Extra Heart Sounds 217

Pumping Action of the Heart 217Lipid Metabolism 217Special Considerations 218

Pediatric Patients 218Geriatric Patients 219

Pregnant Patients 219

PATHOLOGY OVERVIEW 219Coronary Heart Disease 219Angina Pectoris 219

Stable Angina 219Unstable Angina 220Prinzmetal Angina 220

Myocardial Infarction 221Congestive Heart Failure 221

Low-Output Failure 221High-Output Failure 222

CONTENTS

Hypertension 222Arrhythmias 223Lipid Disorders 224

SYSTEM ASSESSMENT 225

Subjective Information 225Chest Pain 225Dyspnea 225Palpitations 227Risk Factors for CHD 227

Objective Information 228Physical Assessment 228

Carotid Arteries 228JugularVeins 229Heart 230Risk Factors for CHD 231

Laboratory and Diagnostic Tests 232Special Considerations 233

Pediatric Patients 233Geriatric Patients 233Pregnant Patients 233

APPLICATION TO PATIENT SYMPTOMS 234Chest Pain 234

Case Study 235Self-Assessment Questions 237Critical Thinking Questions 237

Dyspnea 238Case Study 238

Self-Assessment Questions 241Critical Thinking Questions 241

Palpitations 242Case Study 242

Self-Assessment Questions 244Critical Thinking Questions 244

Risk Factors for C H D 245Case Study 245

Self-Assessment Questions 248Critical Thinking Questions 248

Bibliography 248

13 Peripheral Vascular System 249Rhonda M. Jones

ANATOMY AND PHYSIOLOGY OVERVIEW 249Arteries 249

Arteries in the Arm 249Arteries in the Leg 250

Veins 250Veins in the Arm 251Veins in the Leg 251

Special Considerations 251Pediatric Patients 251Geratric Patients 252Pregnant Patients 252

PATHOLOGY OVERVIEW 252Peripheral Atherosclerosis 252Deep Venous Thrombosis 253

SYSTEM ASSESSMENT 253Subjective Information 253

Leg Pain 253Peripheral Skin Changes 254Edema 254

Objective Information 254Physical Assessment 254Laboratory and Diagnostic Tests 256

Special Considerations 256Pediatric Patients 256Geriatric Patients 256Pregnant Patients 256

APPLICATION TO PATIENT SYMPTOMS 257Case Study 257

Self-Assessment Questions 260Critical Thinking Questions 260

Bibliography 260

14 Gastrointestinal System 261MichaelS. Monaghan

ANATOMY AND PHYSIOLOGY OVERVIEW 261Esophagus 261Stomach 261Small Intestine 262Colon 262Pancreas 262Special Considerations 262

Pediatric Patients 262Geriatric Patients 263Pregnant Patients 263

PATHOLOGY OVERVIEW 263Diarrhea 263Constipation 263Peptic Ulcer Disease 264Gastroesophageal Reflux Disease 265Inflammatory Bowel Disease 266

SYSTEM ASSESSMENT 267

Subjective Information 267Abdominal Pain 268Nausea and Vomiting 268Change in Bowel Habits 269

Objective Information 269Physical Assessment 269Laboratory and Diagnostic Tests 272

Heliocobacter pylori 272Pancreas 273Major Diagnostic Tests 273

Special Considerations 273Pediatric Patients 273Geriatric Patients 273Pregnant Patients 274

Contents

APPLICATION TO PATIENT SYMPTOMS 274

Abdominal Pain 274Case Study 275

Self-Assessment Questions 278Critical Thinking Questions 279

Nausea and Vomi t ing 279

Case Study 279Self-Assessment Questions 281Critical Thinking Questions 281

Change in Bowel Habits 282Case Study 283

Self-Assessment Questions 285Critical Thinking Questions 285

Bibliography 285

15 Hepatic System 286Wendy Mills

ANATOMY AND PHYSIOLOGY OVERVIEW 286

The Liver 286The Gallbladder 286The Pancreas 287Special Considerations 287

Pediatric Patients 287Geriatric Patients 288

Pregnant Patients 288

PATHOLOGY OVERVIEW 288

Hepatitis 288Hepatitis A 288Hepatitis B 288Hepatitis C 289

Cirrhosis 289Drug-Induced Liver Dysfunction 289Pancreatitis 290Cholecystitis 291

SYSTEM ASSESSMENT 291Subjective Information 291

Abdominal Pain 291Ascites 292Jaundice 292

Objective Information 293Physical Assessment 293

The Abdomen 293The Liver 294

Laboratory and Diagnostic Tests 295Special Considerations 296

Pediatric Patients 296Geriatric Patients 296Pregnant Patients 296

APPLICATION TO PATIENT SYMPTOMS 297

Abdominal Pain 297Case Study 297

Self-Assessment Questions 299Critical Thinking Questions 299

Ascites 301Case Study 301

Self-Assessment Questions 302Critical Thinking Questions 302

Jaundice 303Case study 304

Self-Assessment Questions 304Critical Thinking Questions 304

Bibliography 306

16 Renal System 307Rhonda M. Jones

ANATOMY AND PHYSIOLOGY OVERVIEW 307

Kidneys 307Ureters 308Bladder 308Urethra 308Special Considerations 308

Pediatric Patients 308Geriatric Patients 309

Pregnant Patients 309

PATHOLOGY OVERVIEW 309

Renal Failure 309Acute Renal Failure 309Chronic Renal Failure 310

Urinary Tract Infections 310Renal Stones 311

SYSTEM ASSESSMENT 312Subjective Information 312

Urinary Symptoms 312Renal Dysfunction 312

Objective Information 312Physical Assessment 312Laboratory and Diagnostic Tests 313

Special Considerations 315Pediatric Patients 315Geriatric Patients 315Pregnant Patients 315

APPLICATION TO PATIENT SYMPTOMS 315

Oliguria 315Case Study 316

Self-Assessment Questions 317Critical Thinking Questions 317

Bibliography 319

17 Musculoskeletal System 320Amy Friedman Wilson

ANATOMY AND PHYSIOLOGY OVERVIEW 320

Bone 320Joints 321Muscle 324

CONTENTS

Special Considerations 324Pediatric Patients 324Geriatric Patients 326Pregnant Patients 326

PATHOLOGY OVERVIEW 326

Rheumatoid Arthritis 326Osteoarthritis 327Osteoporosis 328Osteomyelitis 329Gout 329Bursitis, Tendinitis, and Tenosynovitis 330Temporomandibular Joint Syndrome 330Trauma 331

SYSTEM ASSESSMENT 331

Subjective Information 331Pain 331Swelling 332Stiffness/Range of Motion 332Weakness 333

Objective Information 334Physical Assessment 334

Gait 334Inspection of the Muscles and

Joints 335Temporomandibular Joint

Syndrome 335Cervical Spine 336Thoracic and Lumbar Spine 336Shoulder 337Elbow 338Wrist and Hand 341Carpal Tunnel Syndrome 342Hip 343Knee 344

Ankle and Foot 346Laboratory and Diagnostic Tests 347

Special Considerations 348Pediatric Patients 348Geriatric Patients 348Pregnant Patients 348

APPLICATION TO PATIENT SYMPTOMS 348

Musculoskeletal Pain 348

Case Study 349Self-Assessment Questions 350Critical Thinking Questions 350

Musculoskeletal Swelling or Edema 352Case Study 352

Self-Assessment Questions 353Critical Thinking Questions 353

Stiffness and Decreased ROM 355Case Study 355

Self-Assessment Questions 358Critical Thinking Questions 358

Bibliography 358

18 Nervous System 359Wendy Mills and Amy Friedman Wilson

ANATOMY AND PHYSIOLOGY OVERVIEW 359

Central Nervous System 359Brain 359Spinal Cord 361

Peripheral Nervous System 362Special Considerations 363

Pediatric Patients 363Geriatric Patients 364Pregnant Patients 364

PATHOLOGY OVERVIEW 364Headache Disorders 364

Tension Headaches 364Migraine Headaches 364Cluster Headaches 365

Epilepsy 365

Partial Seizures 365Generalized Seizures 365Status Epilepticus 365

Parkinson's Disease 366Cerebrovascular Disease 366

Transient Ischemic Attacks 367Cerebrovascular Accidents 367

Peripheral Neuropathy 367SYSTEM ASSESSMENT 368

Subjective Information 368Headache 368Seizures 368Paresthesia 368

Objective Information 369Physical Assessment 369

Cranial Nerve I: Olfactory 369Cranial Nerve II: Optic 369Cranial Nerves III, IV. and VI:

Oculomotor, Trochlear, andAbducens 369

Cranial Nerve V:Trigeminal 369Cranial Nerve VII: Facial 370Cranial Nerve VIII: Acoustic 370Cranial Nerves IX and X:

Glossopharyngeal and Vagus 371Cranial Nerve XI: Spinal Accessory 371Cranial Nerve XII: Hypoglossal 371Motor System 371Gait and Balance 371Coordination 373Sensory Testing 373Reflexes 374

Laboratory and Diagnostic Tests 375Special Considerations 375

Pediatric Patients 375Geriatric Patients 376Pregnant Patients 376

Contents

APPLICATION TO PATIENT SYMPTOMS 376

Headache 376Case Study 377

Self-Assessment Questions 378Critical Thinking Questions 378

Seizures 380Case Study 380

Self-Assessment Questions 382Critical Thinking Questions 382

Paresthesia 382Case Study 382

Self-Assessment Questions 385Critical Thinking Questions 385

Bibliography 385

19 Mental Status 386Karen M. Theesen and Sarah Shoemaker

ANATOMY AND PHYSIOLOGY OVERVIEW 386

The Nervous System 386Special Considerations 387

Pediatric Patients 387Geriatric Patients 387Pregnant Patients 387

PATHOLOGY OVERVIEW 387

Anxiety Disorders 388Adjustment Disorder with Anxiety 388General Anxiety Disorder 388Phobias 388Posttraumatic Stress Disorder 388Panic Attacks 388Obsessive-Compulsive Disorder 389

Mood Disorders 389Adjustment Disorder with Depressed

Mood 389Dysthymic Disorder 389Major Depressive Disorder 389Bipolar Disorder 390

Psychotic Disorders 390Schizophrenia 391

Cognitive Disorders 391Delirium 391Dementia 392

Substance-Use Disorders 393Alcohol 393Sedative-Hypnotics 394Marijuana 394Opioids 395

Stimulants 395

SYSTEM ASSESSMENT 395

Subjective Information 395General Appearance and Attitude 396Behavior 396Cognitive Functioning 397

Orientation to Time, Place, andPerson 397

Concentration and Attention Span 397Immediate, Recent, and Long-Term

Memory 397Abstract Reasoning 398Insight and Judgment 398Ability to Perform Complex Acts 398Level of Ambivalence 398

Thought Processes, Content andPerceptions 398Logic, Relevance, Organization, and

Coherence ofThought Processes 398Thought Content 399Risk for Suicide 399Altered Perceptions of the Senses 399

Objective Information 400Physical Assessment 400Laboratory and Diagnostic Tests 400

Mini-Mental Status Examination 400Special Considerations 401

Pediatric Patients 401Geriatric Patients 402Pregnant Patients 402

APPLICATION TO PATIENT SYMPTOMS 402Memory Problems 403

Case Study 403Self-Assessment Questions 405Critical Thinking Questions 405

Depression 406Case Study 406

Self-Assessment Questions 408Critical Thinking Questions 408

Nervousness 409Case Study 409

Self-Assessment Questions 411Critical Thinking Questions 411

Bibliography 4X2

20 Endocrine System 413Mary Ann Skrabal

ANATOMY AND PHYSIOLOGY OVERVIEW 413

Carbohydrate Metabolism 413Thyroid Function 414Special Considerations 414

Pediatric Patients 414Geriatric Patients 416

Pregnant Patients 417

PATHOLOGY OVERVIEW 417

Diabetes Mellitus 417

Thyroid Disorders 419

SYSTEM ASSESSMENT 420

Subjective Information 420Polyuria 420Fatigue 421

CONTENTS

Objective Information 421Physical Assessment 421

Vital Signs 421Extremities (Hands and Feet) 422Thyroid Gland 423Eyes 424Skin 424Hair 424Nails 425

Laboratory and Diagnostic Tests 425Special Considerations 426

Pediatric Patients 426Geriatric Patients 427Pregnant Patients 427

APPLICATION TO PATIENT SYMPTOMS 428

Polyuria 428Case Study 428

Self-Assessment Questions 430Critical Thinking Questions 430

Fatigue 432Case Study 432

Self-Assessment Questions 434Critical Thinking Questions 434

Bibliography 435

21 The Male Patient 436Julie A. Hixson-Wallace and Raylene M. Rospond

ANATOMY AND PHYSIOLOGY OVERVIEW 436Breasts 436External Genitalia 436Internal Genitalia 437Special Considerations 437

Pediatric Patients 437Geriatric Patients 439

PATHOLOGY OVERVIEW 439Gynecomastia 439Lesions Palpable in the Scrotum 440Hernia 441Tinea Infection 443Erectile Dysfunction 443Benign Prostatic Hyperplasia 443

SYSTEM ASSESSMENT 444Subjective Information 444

Enlarged Breasts 444Lump in the Scrotum 445Bulge in the Groin 445Genital Itching 445Urinary Retention 446Impotence 446

Objective Information 446Physical Assessment 447

Penis and Scrotum 447Femoral and Inguinal Areas 447Prostate 448

Laboratory and Diagnostic Tests 448

Special Considerations 449Pediatric Patients 449Geriatric Patients 449

APPLICATION TO PATIENT SYMPTOMS 449Enlarged Breasts 449

S o : - ' A ; , , - . , , . , , f , r > ; C

r,•:;•,- | ! T h ! n l : n : ; C

Testicular Lump 453

0 1

S-! A.s-s.mf-nt Qu-,!:o-

("••••„• t| fh .nhru- On,",\:or.

Bulge in the Groin 455C.iso Study -»55

Seit Assessment Questions o"~Critical I hinkin'4 Questions -(57

Genital Itching 457Cd-,c Study -»5K

Seit Assessment Questions -i59Critical Thinhn;' Quest ions 4Sl)

Urinary Retention 459Case Stud/ '(S1)

Self-Assessment Questions -iMCritical Thmhng Questions -)6I

Bibliography 462

22 The Female Patient 463Julie A. Hixson-Wallace and Raylene M. Rospond

ANATOMY AND PHYSIOLOGY OVERVIEW 463Breasts and Axillae 463

Surface Anatomy 463Internal Anatomy 463

External Genitalia 464Internal Genitalia 465

Anatomy 465Menstrual Cycle 465

Special Considerations 466Pediatric Patients 466Geriatric Patients 467Pregnant Patients 467

PATHOLOGY OVERVIEW 467Fibrocystic Changes of the Breast 467Breast Cancer 467Vulvovaginal Candidiasis 469Premenstrual Syndrome 469

SYSTEM ASSESSMENT 470Subjective Information 470

Breast Lump 470Vaginal Discharge 471Abdominal Cramping 472

Objective Information 472Physical Assessment 472

Breasts and Axillae 472External Genitalia and Internal

Organs 473

Contents I xxii

Laboratory and Diagnostic Tests 475 Abdominal Cramping 481Special Considerations 475 Case Study 481

Pediatric Patients 475 Self-Assessment Questions 483Geriatric Patients 476 Critical Thinking Questions 483Pregnant Patients 476 Bibliography 483

APPLICATION TO PATIENT SYMPTOMS 476

Breast Lump 476 Answers to Self-Assessment Questions 485Case Study 477 Glossary 495

Self-Assessment Questions 478Critical Thinking Questions 478

Vaginal Discharge 478Case Study 479

Self-Assessment Questions 481Critical Thinking Questions 481