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Describing the Abdomen. Abdomen split into quadrants to help organize organs. Describing the Abdomen. The abdomen can also be split into 9 sections as well. Right Upper Quadrant (RUQ). Liver & Gallbladder Head of Pancreas Duodenum Right adrenal gland Hepatic flexure of colon - PowerPoint PPT Presentation
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 5
Describing the AbdomenDescribing the Abdomen
Abdomen Abdomen split into split into quadrants to quadrants to help organize help organize organs. organs.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 6
Describing the AbdomenDescribing the Abdomen
The The abdomen abdomen can also be can also be split into 9 split into 9 sections as sections as well. well.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 7
Right Upper Quadrant (RUQ)Right Upper Quadrant (RUQ)
Liver & GallbladderLiver & Gallbladder
Head of PancreasHead of Pancreas
DuodenumDuodenum
Right adrenal glandRight adrenal gland
Hepatic flexure of colonHepatic flexure of colon
Portion of right kidneyPortion of right kidney
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 8
Right Lower Quadrant (RLQ)Right Lower Quadrant (RLQ)
AppendixAppendix
Ascending colonAscending colon
OvaryOvary
Right ureterRight ureter
Bladder Bladder
UterusUterus
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 9
Left Upper Quadrant (LUQ)Left Upper Quadrant (LUQ)
SpleenSpleen
StomachStomach
PancreasPancreas
Left lobe of liverLeft lobe of liver
Splenic flexure of colonSplenic flexure of colon
Portions of transverse and descending colonPortions of transverse and descending colon
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 10
Left Lower Quadrant (LLQ)Left Lower Quadrant (LLQ)
Lower left kidneyLower left kidney
Sigmoid colonSigmoid colon
OvaryOvary
Left ureterLeft ureter
Descending colonDescending colon
Bladder Bladder
UterusUterus
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 11
Assessing the AbdomenAssessing the Abdomen
Chief complaintChief complaint
History of present illnessHistory of present illness
Past medical historyPast medical history
Family historyFamily history
Personal/Social historyPersonal/Social history
Physical ExamPhysical Exam
DifferentialDifferential
LabsLabs
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 12
Importance of History Present IllnessImportance of History Present Illness
GI versus cardiac causesGI versus cardiac causes
Clues to DifferentialClues to Differential
Abdominal “Review of Systems”Abdominal “Review of Systems”
Seven attributes of a symptomSeven attributes of a symptom
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 13
Review of Systems for the AbdomenReview of Systems for the Abdomen
Abdominal painAbdominal pain
IndigestionIndigestion
NauseaNausea
VomitingVomiting
DiarrheaDiarrhea
ConstipationConstipation
JaundiceJaundice
DysuriaDysuria
Urinary frequencyUrinary frequency
HematuriaHematuria
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 14
Past Medical HistoryPast Medical History
Gastrointestinal disordersGastrointestinal disorders Urinary Tract InfectionsUrinary Tract Infections SurgeriesSurgeries Medications/ImmunizationsMedications/Immunizations Trauma/InjuryTrauma/Injury Blood transfusionsBlood transfusions HepatitisHepatitis CancerCancer
• Review of Related History
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 15
Family HistoryFamily History
Familial Mediterranean FeverFamilial Mediterranean Fever Inflammatory bowel diseaseInflammatory bowel disease Familial cancer syndromesFamilial cancer syndromes Congenital malformationsCongenital malformations Cystic fibrosis, Celiac’sCystic fibrosis, Celiac’s Kidney diseaseKidney disease Gallbladder diseaseGallbladder disease
• Review of Related History
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 16
Personal and Social HistoryPersonal and Social History
NutritionNutrition
LMP (first day of last menstrual period)LMP (first day of last menstrual period)
Stressful life eventsStressful life events
Travel /Exposure to infectious diseasesTravel /Exposure to infectious diseases
Sexual historySexual history
Use of alcohol and/or illicit drugsUse of alcohol and/or illicit drugs
Tobacco useTobacco use
• Review of Related History
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 17
Pregnant WomenPregnant Women
Urinary symptomsUrinary symptoms Frequency, urgency, burning, suprapubic painFrequency, urgency, burning, suprapubic pain Back painBack pain
Abdominal painAbdominal pain ContractionsContractions
Onset, frequency, duration, intensityOnset, frequency, duration, intensity Leakage of fluid, bloodLeakage of fluid, blood
• Review of Related History
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 18
Older AdultsOlder Adults
Urinary Tract InfectionsUrinary Tract Infections
ConstipationConstipation
IndigestionIndigestion
Dietary habitsDietary habits
• Review of Related History
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 19
Abdominal ExamAbdominal Exam
PreparationPreparation
InspectionInspection
AuscultationAuscultation
PercussionPercussion
PalpationPalpation
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 20
Preparation for the Abdominal ExamPreparation for the Abdominal Exam
Empty bladderEmpty bladder
PositioningPositioning
Abdomen exposureAbdomen exposure
Visualize anatomyVisualize anatomy
Warm hands & stethoscope Warm hands & stethoscope
Approach from the rightApproach from the right
Remember chief complaintRemember chief complaint
Watch faceWatch face
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 21
Inspection (1)Inspection (1)
Skin characteristics: color, striae, rashes, Skin characteristics: color, striae, rashes, lesions, scars, dilated veinslesions, scars, dilated veins
Umbilicus: location, displacement, Umbilicus: location, displacement, inflammationinflammation
Contour: rounded, flat, scaphoidContour: rounded, flat, scaphoid
Symmetry: symmetric, bulges, distensionSymmetry: symmetric, bulges, distension
Surface Motion: pulsations, peristalsisSurface Motion: pulsations, peristalsis
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 22
AuscultationAuscultation
Bowel sounds: frequency, characterBowel sounds: frequency, character
Vascular sounds: bruits, venous humsVascular sounds: bruits, venous hums
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 23
Percussion (1)Percussion (1)
Assess size & density of organsAssess size & density of organs
Detect presence of fluid, air, masses, Detect presence of fluid, air, masses, tendernesstenderness
Can be done independently or concurrently Can be done independently or concurrently with palpationwith palpation
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 24
Percussion (2)Percussion (2)
All quadrants: tympany vs dullnessAll quadrants: tympany vs dullness
Liver span: at right MCL and at the MSL if Liver span: at right MCL and at the MSL if enlargedenlarged
Spleen percussion sign: lowest left ICS Spleen percussion sign: lowest left ICS before & after deep breathbefore & after deep breath
Gastric bubble: left lower anterior rib cage, Gastric bubble: left lower anterior rib cage, left epigastric arealeft epigastric area
Kidneys: costovertebral angleKidneys: costovertebral angle
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 25
Percussion (3)Percussion (3)
If suspect ascites as result of percussion of If suspect ascites as result of percussion of abdominal wall may perform two additional abdominal wall may perform two additional tests: Shifting Dullness Test and the Fluid tests: Shifting Dullness Test and the Fluid Wave Test Wave Test
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 26
Palpation (1)Palpation (1)
Evaluation of organs for: size, shape, Evaluation of organs for: size, shape, consistency, tendernessconsistency, tenderness
Evaluate umbilical ringEvaluate umbilical ring
Palpate for pulsation of abdominal aortaPalpate for pulsation of abdominal aorta
Detection of massesDetection of masses
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 27
Palpation (2)Palpation (2)
Light Palpation: all 4 quadrants; identify Light Palpation: all 4 quadrants; identify muscular resistance, tenderness, massesmuscular resistance, tenderness, masses
Deep palpation: all 4 quadrants; delineate Deep palpation: all 4 quadrants; delineate organs and detect deeper massesorgans and detect deeper masses
Mass: location, size, shape, consistency, Mass: location, size, shape, consistency, tenderness, pulsation, mobility, movement tenderness, pulsation, mobility, movement with respiration, superficial or intra-abdominalwith respiration, superficial or intra-abdominal
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 28
Palpation (3)Palpation (3)
Liver: palpate lower border of right costal Liver: palpate lower border of right costal marginmargin
Aorta: for pulsationAorta: for pulsation
Bladder: distensionBladder: distension
Gallbladder, Spleen, Kidney not often done Gallbladder, Spleen, Kidney not often done unless physician suspects abnormalityunless physician suspects abnormality
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 29
Additional Abdominal TestsAdditional Abdominal Tests
Rebound tendernessRebound tenderness
Iliopsoas muscle testIliopsoas muscle test
Obturator muscle testObturator muscle test
• Examination and Findings
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 30
Abdominal Signs/Associated Abdominal Signs/Associated ConditionsConditions
Blumberg (rebound tenderness)Blumberg (rebound tenderness)
Cullen: ecchymosis around umbilicusCullen: ecchymosis around umbilicus
Grey Turner: ecchymosis of flanksGrey Turner: ecchymosis of flanks
Kehr: abdominal pain radiating to left shoulderKehr: abdominal pain radiating to left shoulder
Markel (heel jar test): up on toes, fall back on heelsMarkel (heel jar test): up on toes, fall back on heels
McBurney: rebound tenderness,pain over appendix McBurney: rebound tenderness,pain over appendix
Murphy: abrupt cessation of respiration when Murphy: abrupt cessation of respiration when gallbladder palpatedgallbladder palpated
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 31
Differential by Anatomic Region-RUQDifferential by Anatomic Region-RUQ
Duodenal ulcerDuodenal ulcer
HepatomegalyHepatomegaly
HepatitisHepatitis
PneumoniaPneumonia
CholecystitisCholecystitis
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 32
Differential by Anatomic Region-LUQDifferential by Anatomic Region-LUQ
Ruptured spleenRuptured spleen
Gastric ulcerGastric ulcer
Aortic aneurysmAortic aneurysm
Perforated colonPerforated colon
PneumoniaPneumonia
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 33
Differential by Anatomic Region-Differential by Anatomic Region-Periumbilical RegionPeriumbilical Region
Intestinal obstructionIntestinal obstruction
Acute pancreatitisAcute pancreatitis
Early appendicitisEarly appendicitis
Mesenteric thrombosisMesenteric thrombosis
Aortic aneurysmAortic aneurysm
DiverticulitisDiverticulitis
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 34
Differential by Anatomic Region-RLQDifferential by Anatomic Region-RLQ
AppendicitisAppendicitis
Ovarian cyst or mass/salpingitisOvarian cyst or mass/salpingitis
Ruptured ectopic pregnancyRuptured ectopic pregnancy
Renal/ureteral stoneRenal/ureteral stone
Strangulated herniaStrangulated hernia
Perforated cecum/regional ileitisPerforated cecum/regional ileitis
DiverticulitisDiverticulitis
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 35
Differential by Anatomic Region-LLQDifferential by Anatomic Region-LLQ
Ovarian cyst or mass/salpingitisOvarian cyst or mass/salpingitis
Ruptured ectopic pregnancyRuptured ectopic pregnancy
DiverticulitisDiverticulitis
Renal/ureteral stoneRenal/ureteral stone
Strangulated herniaStrangulated hernia
Ulcerative colitisUlcerative colitis
Perforated colon/regional ileitisPerforated colon/regional ileitis
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 36
Acute AppendicitisAcute Appendicitis
Pain characteristic: periumbilical or Pain characteristic: periumbilical or epigastric; later localized to RLQ, +McBurneyepigastric; later localized to RLQ, +McBurney
Associated findings: anorexia, nausea, Associated findings: anorexia, nausea, possible vomiting, low grade fever, guarding, possible vomiting, low grade fever, guarding, +rebound tenderness, +iliopsas, +obturator, +rebound tenderness, +iliopsas, +obturator, +McBurney, +Markle+McBurney, +Markle
Peritonitis possible if rupture occurs: Peritonitis possible if rupture occurs: guarding, shallow respirations, hypotension guarding, shallow respirations, hypotension or shock, reduced or absent bowel sounds; or shock, reduced or absent bowel sounds; can be life-threateningcan be life-threatening
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 37
Acute CholecystitisAcute Cholecystitis
Pain: severe pain in RUQ, epigastric or Pain: severe pain in RUQ, epigastric or umbilical pain; lasting 2-4 hours; after meals umbilical pain; lasting 2-4 hours; after meals and especially after fatty meal; may be and especially after fatty meal; may be referred to right subscapular areareferred to right subscapular area
Associated findings: RUQ tenderness & Associated findings: RUQ tenderness & rigidity, +Murphy sign, palpable gallbladder, rigidity, +Murphy sign, palpable gallbladder, anorexia, vomiting, flatulence, fever; possible anorexia, vomiting, flatulence, fever; possible jaundicejaundice
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 38
Acute PancreatitisAcute Pancreatitis
Pain: dramatic, sudden, excruciating LUQ, Pain: dramatic, sudden, excruciating LUQ, epigastric, or umbilical pain; may be present epigastric, or umbilical pain; may be present in one or both flanks with possible in one or both flanks with possible ecchymosis; pain may be referred to left ecchymosis; pain may be referred to left shouldershoulder
Associated findings: epigastric tenderness, Associated findings: epigastric tenderness, vomiting, fever, shock; +Grey Turner and vomiting, fever, shock; +Grey Turner and Cullen signs which occur 2-3 days after onsetCullen signs which occur 2-3 days after onset
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 39
Ectopic PregnancyEctopic Pregnancy
Pain: history of vague abdominal pain Pain: history of vague abdominal pain followed by sudden severe abdominal followed by sudden severe abdominal tenderness in LQ, especially on involved sidetenderness in LQ, especially on involved side
Associated findings: hypogastric tenderness, Associated findings: hypogastric tenderness, symptoms of pregnancy, spotting, missed symptoms of pregnancy, spotting, missed period, mass on bimanual pelvic exam; if period, mass on bimanual pelvic exam; if ruptured: shock, rigid abdominal wall, ruptured: shock, rigid abdominal wall, distension, + Kehr, + Cullendistension, + Kehr, + Cullen
Mittleschmertz: pain associated w/ovulationMittleschmertz: pain associated w/ovulation
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 40
Acute HepatitisAcute Hepatitis
Pain: general abdominal discomfort; malaisePain: general abdominal discomfort; malaise
Associated findings: jaundice, clay-colored Associated findings: jaundice, clay-colored stools and dark urine which may preceed stools and dark urine which may preceed jaundice by 1 to 5 days, enlarged liverjaundice by 1 to 5 days, enlarged liver
Patients with cirrhosis: will also have ascites, Patients with cirrhosis: will also have ascites, prominent abdominal vasculature, cutaneous prominent abdominal vasculature, cutaneous spider angiomas, generalized itchingspider angiomas, generalized itching
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 41
Perforated Gastric or Duodenal UlcerPerforated Gastric or Duodenal Ulcer
Pain: abrupt RUQ; may be referred to Pain: abrupt RUQ; may be referred to shouldersshoulders
Associated findings: abdominal free air and Associated findings: abdominal free air and distension with increased resonance over distension with increased resonance over liver; tenderness in epigastrum or RUQ; rigid liver; tenderness in epigastrum or RUQ; rigid abdominal wall, rebound tenderness; abdominal wall, rebound tenderness; hematemesis, melena, hypotension, hematemesis, melena, hypotension, increased pulse rate; “acute abdomen” is a increased pulse rate; “acute abdomen” is a life-threatening eventlife-threatening event
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 42
Abdominal Aortic AneurysmAbdominal Aortic Aneurysm
Pain: painless but pain may indicate Pain: painless but pain may indicate imminent rupture; steady throbbing midline imminent rupture; steady throbbing midline pain over aneurysm which may radiate to pain over aneurysm which may radiate to back, flankback, flank
Associated findings: nausea, vomiting, Associated findings: nausea, vomiting, prominent aortic pulsation, bruit and or massprominent aortic pulsation, bruit and or mass
Life-threatening even if occurs in hospital Life-threatening even if occurs in hospital settingsetting
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 43
PyelonephritisPyelonephritis
Pain: flank pain, back painPain: flank pain, back pain
Associated findings: malaise, dysuria, Associated findings: malaise, dysuria, nocturia, urinary frequency, possible fever, + nocturia, urinary frequency, possible fever, + costovertebral angle tendernesscostovertebral angle tenderness
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 44
Renal CalculiRenal Calculi
Pain: intense flank pain extending to groin & Pain: intense flank pain extending to groin & genital area; may be episodicgenital area; may be episodic
Associated findings: fever, hematuria, + KehrAssociated findings: fever, hematuria, + Kehr
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 45
Irritable Bowel SyndromeIrritable Bowel Syndrome
Pain: crampy, variable hypogastric pain; Pain: crampy, variable hypogastric pain; associated with abdominal bloating, associated with abdominal bloating, distension; + bowel soundsdistension; + bowel sounds
Associated symptoms: flatus, constipation or Associated symptoms: flatus, constipation or diarrhea; may see mucous in stool; relief with diarrhea; may see mucous in stool; relief with passage of flatus or bowel movementpassage of flatus or bowel movement
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 46
DiverticulitisDiverticulitis
Pain: epigastric, radiating down left side of Pain: epigastric, radiating down left side of abdomen especially after eating; may be abdomen especially after eating; may be referred to backreferred to back
Associated findings: tenderness on Associated findings: tenderness on palpation, borborygmus, flatulence, diarrhea, palpation, borborygmus, flatulence, diarrhea, possibly dysuriapossibly dysuria
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 47
Acute DiarrheaAcute Diarrhea
Pain: abrupt onset of crampy painPain: abrupt onset of crampy pain
Associated findings: increased bowel Associated findings: increased bowel sounds, diarrhea, nausea, vomiting, fever, sounds, diarrhea, nausea, vomiting, fever, and tenesmus; consider food poisoning if and tenesmus; consider food poisoning if develops in 2 or more following ingestion of develops in 2 or more following ingestion of same foodsame food
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 48
HerniaHernia
Pain: localized pain that increases with lifting Pain: localized pain that increases with lifting or exertionor exertion
Associated findings: hernia on physical Associated findings: hernia on physical exam, history of abdominal trauma, surgeryexam, history of abdominal trauma, surgery
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 49
ReferencesReferences
Mosby’s Guide to Physical Examination, 6Mosby’s Guide to Physical Examination, 6 thth Edition. Chapter 17 pp 521-578.Edition. Chapter 17 pp 521-578.
Bates’ Guide to Physical Examination and Bates’ Guide to Physical Examination and History Taking. Chapter 9 pp 317-366.History Taking. Chapter 9 pp 317-366.
University of California, San Diego “A University of California, San Diego “A Practical Guide to Clinical Medicine” Practical Guide to Clinical Medicine” Accessed online 02/09/07 at Accessed online 02/09/07 at medicine.ucsd.edu/clinicalmedicine/medicine.ucsd.edu/clinicalmedicine/
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