Interactive Guide to Physical Examination
hair:
distribution: With arterial insufficiency there is loss of hair over the lower extremity. You may note over the toes loss of hair as well as fine wrinkling of the skin.
patches: A patch of hair over the sacrum can sometimes be a variant of normal, but can also be associated with neural tube defects, including spina bifida occulta.
pattern of loss: Male pattern balding, or androgenic hair loss, is the most common type of hair loss. This can be seen in some 30-40% of adult men and women. It is genetically determined and tends to occur for women during the menopausal years. In women, the pattern tends to be thinning in the vertex and frontal regions. In men, the pattern tends to represent an "M" with excessive temporal regression to the mid scalp. In contrast, telogen effluvien tends to be diffuse hair loss and is associated with an acute illness or life event.
head and neck, cancer of: Head and neck cancers are primarily squamous cell carcinomas. They are generally uncommon cancers, affecting men more commonly than women. Nearly all head and neck cancers are associated with the use of alcohol and tobacco; agents which are multiplicative in their risk for associated oral carcinoma. A special exception is nasopharyngeal carcinoma, which is very common in the Middle East and north Africa and associated with Epstein-Barr virus infection. Early signs and symptoms may be vague, such as epistaxis, nasal obstructive symptoms, nonhealing ulcers, or otalgia, to name a few. Any non-healing oral lesion should be biopsied to rule out carcinoma. Radiotherapy, surgery, and chemotherapy are all therapies used to treat head and neck cancer. Go to page
heart:
apex: The narrower, bottom portion of the heart is termed the apex. The apex sits to the left of the sternum, at approximately the fifth intercostal space. The apical impulse, formed by the left ventricle, can be evaluated best in this area. In addition, the opening and closing of the atrioventricular valves can be evaluated here.
base: The base of the heart refers to the broader, upper border of the heart which lies at about the third intercostal space. This is where the pulmonary artery joins the right ventricle, the aorta leaves the left ventricle, and the superior vena cava empties into the right atrium. Impulses related to these structures or associated cardiac valves can be palpated in this area. In addition, heart sounds related to the semilunar valves are often best heard in this location.
impairing right filling: The jugular venous pressure reflects right atrial events. Right ventricular hypertrophy, tricuspid valve disease, right heart failure, constrictive disease or tamponade all cause characteristic changes in the jugular venous pressure and wave form.
rate: Most commonly the heart rate is evaluated by palpating the arterial pulse, counting the rate over 15 seconds, and multiplying by four. If the rhythm seems irregular, not all beats may be detected peripherally, so a more accurate estimate of the heart rate may be obtained by auscultating over the precordium and counting the rate here. The normal heart rate at rest is between 60 and 100. A heart rate over 100 is referred to as tachycardia whereas a heart rate under 60 is referred to as bradycardia.
heave: a palpable cardiac apical impulse, more vigorous or longer than expected.
hemiballismus: Hemiballismus is a sustained, violent, flinging movement of a limb occurring often as a result of a lesion in the contralateral subthalamic nucleus and/or adjacent structures. Go to page
hepatic tumors: Patients at risk for hepatic tumors include patients with know malignancies, chronic hepatitis B infection, hepatitis C infection, or sclerosing cholangitis. A friction rub or bruit over the liver is a fairly rare finding however. Go to page
hepatomegaly: Hepatomegaly is enlargement of the liver, generally greater than 12 cm in vertical span in the midclavicular line, or greater than 8 cm in the midsternal line. There are many reasons for enlargement of the liver, including: fatty infiltration, passive congestion from heart failure, acute hepatitis, and infiltration with tumor. Go to page
hip, surface landmarks of: Knowing the surface landmarks of the hip is critical to the physical exam of this region. The anterior landmarks include the iliac crest, iliac tubercle, and anterior superior iliac spine. Posteriorly, the landmarks the posterior superior iliac spine, the greater trochanter, the ischial tuberosity, and the sciatic nerve. Go to page
hyperinflation: Hyperinflation of the lungs is overinflation with air as seen with emphysema or acute asthmatic attacks. The percussion note is hyperresonant and tactile fremitus is often decreased. Go to page
hyper-resonant note: A percussion note that is deemed hyper-resonant is generally louder than normal, has a somewhat lower pitch than a normal resonant sound, and lasts somewhat longer. Hyperresonant notes are heard over hyperinflated lungs such as in emphysema. Go to page
hypersensitivity: Hypersensitivity refers to increased sensation in a particular region. Injury of large diameter sensory nerve fibers may cause paresthesias (the sensation of pins and needles). Injured small diameter sensory nerve fibers may cause feelings of intense warmth, burning, or itching. Stroking the skin in the affected area may make these sensations more intense. Go to page
hypertension: Hypertension affects 32% of the non-Hispanic black population and 23% of the non-Hispanic white population and Mexican-American population. Hypertension increases the risk for premature cardiovascular disease, congestive heart failure, left ventricular hypertrophy (with its association with sudden death), stroke, intracerebral hemorrhage, chronic renal failure and end stage renal disease. To diagnose hypertension, the average of two or more blood pressure readings, obtained at two or more office visits, are used. The Joint National Committee (JNC-6) has defined hypertension as:
hypertrophic cardiomyopathy: Hypertrophic cardiomyopathy is a genetic disease characterized by left ventricular hypertrophy. The clinical and hemodynamic consequences are quite variable. On physical exam there may be no abnormal findings or just an S4. With progressive obstruction however a harsh, crescendo-decrescendo, systolic murmur may be heard best at the apex and lower left sternal border. With standing and thus a decrease in left ventricular volume, the degree of obstruction to outflow increases and the intensity of the murmur increases. In contrast, with squatting (or the release of the Valsalva maneuver) there is an increase in left ventricular volume and thus the outflow to obstruction is lessened resulting in a decrease in the intensity of the murmur. Go to page
hypothyroidism: Hypothyroidism results from the decreased secretion of thyroid hormone secondary to: unknown cause, surgical ablation, inflammation, pituitary failure, irradiation, thyroiditis, or tumor replacement of the thyroid gland. In hypothyroidism there may be evidence of periorbital edema, loss of the lateral margin of the eyebrows, and proptosis or bulging of the eyes. In addition, the hair may be coarse and thinned and the skin pale, cool, and dry. Lastly, the tongue may be enlarged.
