♦ A symmetrical, lesion-free skull

♦ Symmetrical facial structures with normal variations in skin texture and pigmentation

♦ An ability to shrug the shoulders, a sign of an adequately functioning cranial nerve XI (accessory nerve)

♦ Unrestricted range of motion in the neck

♦ No bulging of the thyroid

♦ Symmetrical lymph nodes with no swelling

♦ Flat jugular veins

♦ No lumps or tenderness on the head

♦ Symmetrical strength in the facial muscles, a sign of adequately functioning cranial nerves V and VII (trigeminal and facial nerves)

♦ Symmetrical sensation when you stroke a wisp of cotton on each cheek

♦ Mobile, soft lymph nodes less than ½″ (1 cm) with no tenderness

♦ Symmetrical pulses in the carotid arteries

♦ A palpable, symmetrical, lesion-free thyroid with no tenderness

♦ Midline location of the trachea and absence of tracheal tenderness

♦ No crepitus, tenderness, or lesions in the cervical spine

♦ Symmetrical muscle strength in the neck

♦ Auscultate the temporal artery

♦ Auscultate for carotid bruits

♦ Symmetrical, lesion-free nose with no deviation of the septum or discharge

♦ Little or no nasal flaring

♦ Nonedematous frontal and maxillary sinuses

♦ Ability to identify familiar odors

♦ Pink-red nasal mucosa with no visible lesions and no purulent drainage

♦ No evidence of foreign bodies or dried blood in the nose

♦ Pink lips with no dryness, cracking, lesions, or cyanosis

♦ Symmetrical facial structures

♦ Ability to purse the lips and puff out the cheeks, a sign of an adequately functioning cranial nerve VII (facial nerve)

♦ Ability to open and close the mouth easily

♦ Light pink, moist oral mucosa with no ulcers or lesions

♦ Visible salivary ducts with no inflammation

♦ White, hard palate

♦ Pink, soft palate

♦ Pink gums with no tartar, inflammation, hemorrhage, or leukoplakia

♦ All teeth intact, with no signs of occlusion, caries, or breakage

♦ Pink tongue that protrudes symmetrically and has no swelling, coating, ulcers, or lesions

♦ Ability to move the tongue easily and without tremor, a sign of a properly functioning cranial nerve XII (hypoglossal nerve)

♦ No swelling or inflammation on the anterior and posterior arches

♦ No lesions or inflammation on the posterior pharynx

♦ Lesion-free tonsils that are the appropriate size for the patient’s age

♦ A uvula that moves upward when the patient says “ah” and a gag reflex that occurs when a tongue blade touches the posterior pharynx. These are signs of properly functioning cranial nerves IX and X.

♦ No structural deviation, tenderness, or swelling on the external nose

♦ No tenderness or edema on the frontal and maxillary sinuses

♦ Lips free from pain and induration

♦ No tenderness on the posterior and lateral surfaces of the tongue

♦ No tenderness or nodules on the floor of the mouth

In allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.

Chronic anxiety is characteristic of conversion disorder, along with one or two somatic complaints that have no physiologic basis. Common complaints are dizziness, chest pain, palpitations, a lump in the throat, and choking.

Acute anxiety may be an early sign of hyperthyroidism. Classic signs include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, and diarrhea. Exophthalmos may occur as well.

Hyperventilation syndrome produces acute anxiety, pallor, circumoral and peripheral paresthesia and, occasionally, carpopedal spasms.

Panic may occur in patients with mitral valve prolapse, which is referred to as the click-murmur syndrome. The disorder may also cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. Its hallmark is a midsystolic click followed by an apical systolic murmur.

In the depressive form of mood disorder, chronic anxiety occurs with varying severity. The hallmark is depression on awakening that abates during the day. Associated findings include dysphoria; anger; insomnia or hypersomnia; decreased libido, interest, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts.

Chronic anxiety occurs in obsessivecompulsive disorder, along with recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational, but can’t control them. Anxiety builds if he can’t perform these acts and diminishes after he does.

In phobias, chronic anxiety occurs along with persistent fear of an object, activity, or situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational, but can’t suppress it.

Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. Associated symptoms include irritability, insomnia, dizziness, and mild headache. The anxiety is usually most pronounced in situations that demand attention, judgment, or comprehension.

Posttraumatic stress disorder produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event
in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.

Most common in adolescents and young adults, somatoform disorder is characterized by chronic anxiety and various somatic complaints that have no physiologic basis. Anxiety and depression may be prominent or hidden by dramatic, flamboyant, or seductive behavior.

Angina pectoris, chronic obstructive pulmonary disease, heart failure, hypochondrial neurosis, hypoglycemia, myocardial infarction (MI), pheochromocytoma, pneumothorax, and pulmonary embolism can cause anxiety. Certain drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. Also, many antidepressants can cause paradoxical anxiety.

Typically, an asthma attack occurs at night, starting with a nonproductive cough and mild wheezing. Then it progresses to audible wheezing, chest tightness, a cough that produces thick mucus, and severe dyspnea. Other signs include accessory muscle use, cyanosis, diaphoresis, flaring nostrils, flushing, intercostal and supraclavicular
retractions on inspiration, prolonged expirations, tachycardia, and tachypnea.

With interstitial lung disease, the patient has a nonproductive cough and progressive dyspnea. He may also be cyanotic and fatigued and have fine crackles, finger clubbing, chest pain, and recent weight loss.

A nonproductive cough may stem from airway occlusion, atelectasis, the common cold, hypersensitivity pneumonitis, pericardial effusion, pleural effusion, pulmonary embolism, Hantavirus infection, and sinusitis. Also, incentive spirometry, intermittent positive-pressure breathing, and suctioning can induce a nonproductive cough.

Acute otitis media, which commonly occurs in infants and young children because of their short eustachian tubes, also produces nonproductive coughing.

With bacterial pneumonia, an initially dry cough becomes productive. Rustcolored sputum appears in pneumococcal pneumonia; brick-red or currantjelly sputum, in Klebsiella pneumonia; salmon-colored sputum, in staphylococcal pneumonia; and mucopurulent sputum, in streptococcal pneumonia.

The cardinal sign of a ruptured lung abscess is coughing that produces
copious amounts of purulent, foulsmelling and, possibly, blood-tinged sputum. A ruptured abscess can also cause anorexia, diaphoresis, dyspnea, fatigue, fever with chills, halitosis, headache, inspiratory crackles, pleuritic chest pain, tubular or amphoric breath sounds, and weight loss.

A productive cough can result from acute bronchiolitis, aspiration and chemical pneumonitis, bronchiectasis, the common cold, cystic fibrosis, lung cancer, pertussis, pulmonary embolism, pulmonary edema, and tracheobronchitis. Also, expectorants, incentive spirometry, and intermittent positive-pressure breathing can cause a productive cough.

GI anthrax manifests after the patient has eaten contaminated meat from an animal infected with Bacillus anthracis. Early signs and symptoms include decreased appetite, nausea, vomiting, and fever. Later signs and symptoms include severe bloody diarrhea, abdominal pain, and hematemesis.

With carcinoid syndrome, severe diarrhea occurs with flushing—usually of the head and neck—that’s commonly caused by emotional stimuli or the ingestion of food, hot water, or alcohol. Associated signs and symptoms include abdominal cramps, dyspnea, weight loss, anorexia, weakness, palpitations, valvular heart disease, and depression.

After ingesting water or food contaminated by the bacterium Vibrio cholerae, the patient experiences abrupt watery diarrhea and vomiting. Other signs and symptoms include thirst (caused by severe water and electrolyte loss),
weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

The patient may be asymptomatic or may have soft, unformed stools or watery diarrhea that may be foul-smelling or grossly bloody; abdominal pain, cramping, and tenderness; fever; and a white blood cell count as high as 20,000/µl. In severe cases, the patient may have toxic megacolon, colonic perforation, or peritonitis.

Crohn’s disease is a recurring inflammatory disorder that produces diarrhea accompanied by abdominal pain with guarding, tenderness, and nausea. The patient may also have fever, chills, weakness, anorexia, and weight loss.

With E. coli infection, the patient has watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps after eating undercooked beef or other foods contaminated with this strain of bacteria. Hemolytic uremic syndrome, which causes red blood cell destruction and eventually acute renal failure, is a complication of E. coli 0157:H7 infection in children age 5 and younger and in elderly people.

Acute viral, bacterial, and protozoal infections (such as cryptosporidiosis) cause the sudden onset of watery diarrhea as well as abdominal pain, cramps, nausea, vomiting, and fever. Significant fluid and electrolyte loss may cause signs of dehydration and shock. Chronic tuberculosis and fungal and parasitic infections may produce less severe but more persistent diarrhea, accompanied by epigastric distress, vomiting, weight loss and, possibly, passage of blood and mucus.

Partial intestinal obstruction increases intestinal motility, resulting in diarrhea, abdominal pain with tenderness and guarding, nausea and, possibly, distention.

Diarrhea alternates with constipation or normal bowel function. The patient may have abdominal pain, tenderness, and distention; dyspepsia; and nausea.

Ischemic bowel disease is a life-threatening disorder that causes bloody diarrhea with abdominal pain. If severe, shock may occur, requiring surgery.

With lactose intolerance, diarrhea occurs within several hours of ingesting milk or milk products. It’s accompanied by cramps, abdominal pain, borborygmi, bloating, nausea, and flatus.

With large-bowel cancer, bloody diarrhea is seen with partial obstruction. Other signs and symptoms include abdominal pain, anorexia, weight loss, weakness, fatigue, exertional dyspnea, and depression.

The hallmark of ulcerative colitis is recurrent bloody diarrhea with pus or mucus. Other signs and symptoms include tenesmus, hyperactive bowel sounds, cramping lower abdominal pain, low-grade fever, anorexia and, at times, nausea and vomiting. Weight loss, anemia, and weakness are late findings.

Many antibiotics—such as ampicillin, cephalosporins, tetracyclines, and clindamycin—cause diarrhea. Other drugs that may cause diarrhea include magnesium-containing antacids, colchicine, guanethidine, lactulose, dantrolene, ethacrynic acid, mefenamic acid, methotrexate, metyrosine and, in high doses, cardiac glycosides and quinidine. Laxative abuse can cause acute or chronic diarrhea. Foods that contain certain oils may inhibit absorption of food, causing acute, uncontrollable diarrhea and rectal leakage. Gastrectomy, gastroenterostomy, and pyloroplasty may produce diarrhea. High-dose radiation therapy may produce enteritis and diarrhea.

Diarrhea in children commonly results from infection, although chronic diarrhea may result from malabsorption syndrome, an anatomic defect, or allergies. Because dehydration and electrolyte imbalance occur rapidly in children, diarrhea can be life-threatening. Diligently monitor all episodes of diarrhea, and immediately replace lost fluids.

A life-threatening condition, upperairway obstruction is marked by mild to severe wheezing and respiratory distress. Dysphagia occurs along with gagging and dysphonia.

In the patient with esophageal carcinoma, painless dysphagia typically accompanies rapid weight loss. As the carcinoma advances, dysphagia becomes painful and constant. The patient has a cough with hemoptysis, hoarseness, sore throat, and steady chest pain.

For patients older than age 50 with head or neck cancer, dysphagia is commonly the initial chief complaint.

A patient with corrosive esophagitis has dysphagia accompanied by excessive salivation, fever, hematemesis, intense pain in the mouth and anterior chest, and tachypnea. Candida esophagitis produces dysphagia and sore throat. In reflux esophagitis, dysphagia is a late symptom that usually accompanies stricture.

The patient with a hiatal hernia may complain of belching, dysphagia, dyspepsia, flatulence, heartburn, regurgitation, and retrosternal or substernal chest pain that’s aggravated by lying down or bending over.

Dysphagia results from botulism, esophageal diverticula or stricture, external esophageal compression, hypocalcemia, laryngeal nerve damage, and Parkinson’s disease. Radiation therapy and tracheotomy may also cause dysphagia.

In acute respiratory distress syndrome (ARDS), acute dyspnea is followed by accessory muscle use, crackles, grunting respirations, progressive respiratory distress, rhonchi, and wheezes. In the
late stages, anxiety, cyanosis, decreased mental acuity, and tachycardia occur. Severe ARDS can produce signs of shock, such as cool, clammy skin and hypotension. The typical patient has no history of underlying cardiac or pulmonary disease, but has had a recent pulmonary or systemic insult.

Inspiratory stridor and acute dyspnea occur as the patient tries to overcome the obstruction. Related findings include accessory muscle use, anxiety, asymmetrical chest expansion, cyanosis, decreased or absent breath sounds, diaphoresis, hypotension, and tachypnea. The patient may have aspirated vomitus or a foreign body or may have been exposed to an allergen.