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Hamilton Bailey s Physical Signs Demonstrations of
Physical Signs in Clinical Surgery 19th Edition Lumley
Digital Instant Download
Author(s): Lumley, John S P;D'Cruz, Anil;Hoballah, Jamal;Scott-Connor,
Carol
ISBN(s): 9781498774840, 1498774849
Edition: 19
File Details: PDF, 254.44 MB
Year: 2016
Language: english
 Hamilton Bailey’s
Demonstrations of Physical
Signs in Clinical Surgery

K17518_Book.indb 1 21/11/15 12:19 am

This page intentionally left blank
 Hamilton Bailey’s
Demonstrations of Physical
Signs in Clinical Surgery
19th Edition

Edited by

John S P Lumley, Emeritus Professor of Vascular Surgery, University of London; Past

Council Member and Chairman of Primary Fellowship Examinations, Royal College of
Surgeons of England, UK

Anil K D’Cruz, Director, Tata Memorial Hospital, Professor & Surgeon, Department of
Head & Neck Surgery, Mumbai, India

Jamal J Hoballah, Professor & Chairman, Department of Surgery, American University

of Beirut Medical Center, Lebanon; Emeritus Professor of Surgery, Vascular Surgery Division,
University of Iowa Hospitals and Clinics, Iowa City, USA

Carol E H Scott-Conner, Emeritus Professor, Division of Surgical Oncology and

Endocrine Surgery, Department of Surgery, University of Iowa Carver College of Medicine,
Iowa City, USA

K17518_Book.indb 3 21/11/15 12:19 am

CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
© 2016 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Version Date: 20160107

International Standard Book Number-13: 978-1-4987-7484-0 (eBook - PDF)

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 Contents

Biography of Hamilton Bailey vii Part Three: Skin 289

List of contributors ix 18 The Skin 291
Preface xi

Part One: Principles 1 Part Four: Head and neck 317

1 H
 istory-taking and General 19 The Head 319
Examination3 20 The Face and Jaws 335
2 Distinctive Clinical Syndromes 23 21 The Ear 343
3 L umps, Ulcers, Sinuses and 22 The Orbit 351
Fistulas53
23 The Mouth 365
4 Inflammation71
24 Nose and Throat 379
5 HIV and AIDS 101
25 Salivary Glands 391
Part Two: Trauma and (elective) 26 The Neck 397
orthopaedics 135
6  anagement of the Multiply Injured
M Part Five: Breast and endocrine 407
Patient137
27 The Thyroid and Parathyroids 409
7 Bones and Fractures 147
28 Breast and Axilla 417
8 Joints and Muscles 167
9 Peripheral Nerve Injuries 177
10 The Spine 187 Part Six: Cardiothoracic431
11 T he Shoulder Joint and 29 T he Thorax (Including the
Pectoral Girdle 207 Oesophagus)433
12 The Arm 217 30 E
 valuation of the Cardiac Surgical
Patient455
13 The Hand 229
14 T he Pelvis, Hip Joint
and Thigh 237 Part Seven: Vascular467
15 The Knee Joint 253 31 Arterial Disorders 469
16 The Leg and Ankle Joint 269 32 V
 enous and Lymphatic
17 The Foot 277 Disorders495

K17518_Book.indb 5 21/11/15 12:19 am

 vi CONTENTS

Part Eight: Abdominal515 38 The Alimentary Tract and Abdomen

33 T he Abdominal Wall, Umbilicus in Children 629
and Groin 517
34 Abdominal Hernias 531
Part Nine: Genitourinary637
35 Non-acute Abdominal Conditions 547
36 The Acute Abdomen 577 39 T he Genitourinary System and
37 A
 norectal and Vaginal Genitalia639
Examination615 Index665

K17518_Book.indb 6 21/11/15 12:19 am

 Hamilton Bailey
1894–1961

Born in Bishopstoke, Hampshire, where his father was a general practitioner, Henry
Hamilton Bailey grew up in Southport, Eastbourne, and Brighton, England, where
his father was successfully in practice. His mother was a nurse, so not surprisingly he
became a medical student at the London Hospital at the early age of sixteen years, after
schooling at St. Lawrence College, Ramsgate.
At the outbreak of the First World War he was a fourth-year medical student, and
volunteered for the Red Cross, being dispatched with the British Expeditionary Force
to Belgium. Almost inevitably he was taken prisoner-of-war and set to work on the
German railways. A troop train was wrecked and Bailey, with two Frenchmen, was
held on suspicion of sabotage. One of the latter was actually executed but Bailey was
reprieved (apparently by the good offices of the American Ambassador in Berlin) and
repatriated via Denmark, where he continued his medical studies temporarily.
In 1916 he joined the Royal Navy as a Surgeon-Probationer, serving in HMS Iron Duke at the Battle of Jutland. During
the battle he helped with casualties in near darkness, the electricity supply being damaged for most of the action. While in
the Navy he qualified, and later returned to the London Hospital, where he gained the FRCS (Eng) in 1920. During his
period as surgical registrar at the London Hospital he pricked his left index finger, and tendon-sheath infection, a common
sequel in those days, ensued. The end result was an amputation of the stiff finger, but he soon overcame the disability.
Appointments as Assistant Surgeon at Liverpool Royal Infirmary, Surgeon to Dudley Road Hospital, Birmingham
(1925), and finally as Surgeon to the Royal Northern Hospital, London (1931) followed.
In a quarter of a century Bailey produced this work, his Emergency Surgery, and Short Practice of Surgery [jointly with
R.J. McNeill Love (1891–1974), contemporary as a surgical registrar at the London Hospital and as a Surgeon at the
Royal Northern Hospital], edited Surgery of Modern Warfare during the Second World War, and revitalized Pye’s Surgical
Handicraft. These were his most successful works; all rapidly attained a wide circulation with many editions, and it has
been said “... it will readily be conceded that the present excellence of illustrations in medical textbooks owes much to
his inspiration and striving for perfection”. In addition to these major contributions, he wrote over 130 original papers
and nine other books.
All this, together with a busy practice, particularly in surgical emergencies, was too much, even for Hamilton Bailey’s
massive frame, and in 1948 he suffered a breakdown in health, aggravated, no doubt, by the death of his only child, a
son, in a railway accident in 1943. He retired to Deal, Kent, and later to Malaga, Spain, but continued his literary work.
He died of carcinoma of the colon, and is buried in the peaceful little English cemetery in Malaga. His missionary zeal for
teaching medical students has been perpetuated by the use of the royalties from his books to expand medical libraries in
developing countries.

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This page intentionally left blank
 Contributors

Dr Ghassan S. Abu-Sittah mbchb frcs (plast), Assistant Shraddha Deshmukh ms dnb, Assistant Professor,
Professor of Surgery, Head of Division of Plastic & Department of Otorhinolaryngology, Government
Reconstructive Surgery, American University of Beirut Medical College, Nagpur, India
Medical Center, Beirut, Lebanon; Honorary Senior Mandar S. Deshpande ms (general surgery) dnb,
Clinical Lecturer, Queen Mary University of London, UK Consultant Head and Neck Surgeon, Kokilaben
Badih Adada md frcs, Cleveland Clinic Florida, FL, USA Dhirubhai Ambani Hospital, Mumbai, India
Muhyeddine Al-Taki md facs, Assistant Professor of Parul Deshpande ms (ophthalmology) dnb, Fellowship
Clinical Surgery, American University of Beirut Medical (Cornea and Anterior segment) Ophthalmologist and
Center, Beirut, Lebanon Cornea Specialist, Sarvodaya Eye Hospital, Mumbai,
Parth Amin md, Clinical Assistant Professor, Western India
Michigan University School of Medicine, Kalamazoo, Jesse Dirksen md, Surgical Director, Edith Sanford Breast
MI, USA Center, Sioux Falls, SD, USA
Evgeny V. Arshava md facs, Clinical Assistant Professor, Celia M. Divino md facs, Department of Surgery, Mount
Division Acute Care Surgery, Department of Surgery, Sinai School of Medicine, New York, NY, USA
University of Iowa Hospitals and Clinics, Iowa City, Abdel Kader El Tal md, Procedural Dermatology,
IA, USA Dermatology Associates Inc. Perrysburg, OH, USA
Andrea Badillo md, Assistant Professor of Surgery, Rachid Haidar md facs, Head of Division of Orthopedic
Attending Pediatric Surgeon, Children’s National Surgery, Professor of Clinical Orthopaedic Surgery,
Healthcare System, George Washington University, Department of Surgery, American University of Beirut
Washington DC, USA Medical Center, Beirut, Lebanon
Jamil Borgi md, Cardiothoracic Surgery Senior Staff, Ali Hallal md frcs (ed), Assistant Professor of Clinical
Division of Cardiac Surgery, Henry Ford Hospital, Surgery, General and Upper Gastro-Intestinal Surgery,
Detroit, MI, USA Trauma Surgery and Intensive Care, Program Director,
John Byrn md, Department of Surgery, University of Trauma and Surgical Critical Care Fellowship,
Michigan, Ann Arbor, MI, USA Department of Surgery, American University of Beirut
Devendra Chaukar ms (general surgery) dnb, Professor Medical Center, Beirut, Lebanon
and Head, Division of Head and Neck, Tata Memorial Natalie Anne Hirst bsc mbbs mrcs, Clinical Research
Hospital, Mumbai, India Fellow, St James’s University Hospital, Leeds, UK
William Cross bmed sci bm bs frcs (urol) phd, Consultant Jamal J. Hoballah Professor & Chairman, Department of
Urological Surgeon, St James’s University Hospital, Surgery, American University of Beirut Medical Center,
Leeds, UK Beirut, Lebanon; Emeritus Professor of Surgery, Vascular
Anil K. D’Cruz ms dnb frcs (hon), Director, Tata Surgery Division, University of Iowa Hospitals and
Memorial Hospital, Professor and Surgeon, Head and Clinics, Iowa City, IA, USA
Neck Services, Tata Memorial Hospital, Mumbai, India Maen Aboul Hosn md febs, Division of Vascular Surgery,
Mitali Dandekar ms dnb, Clinical Fellow, Department of University of Iowa Hospitals and Clinics, Iowa City, IA,
Head Neck Surgery, Tata Memorial Centre, Mumbai, USA
India Hamed Janom md, Surgical Resident, PGY5, Division of
Anuja D. Deshmukh ms (ent) dlo dorl, Associate Plastic and Reconstructive Surgery, American University
Professor and Associate Surgeon, Department of Head of Beirut Medical Center, Beirut, Lebanon
and Neck Surgical Oncology, Tata Memorial Centre, Subbiah Kannan ms (ent), Fellow (Head and Neck Onco-
Mumbai, India surgery), Consultant Head and Neck Onco-surgeon,
Apollo Speciality Hospital, Chennai, India

K17518_Book.indb 9 23/11/15 11:05 am

 x CONTRIBUTORS

Firas Kawtharani md, Chief Resident, Orthopaedic Elie P. Ramly md, Surgery Resident, Department of
Surgery, American University of Beirut Medical Center, Surgery, Oregon Health and Science University,
Beirut, Lebanon Portland, OR, USA
Murad Lala ms (general surgery), mch (­surgical S. Girish Rao mds fdsrcs (eng) ffdrcsi (ire), Professor
oncology) fics, Consultant Surgical Oncologist,
& Head, Department of Maxillofacial Surgery, RV
Department of Surgical Oncology, P. D. Hinduja
Dental College Bangalore, India
National Hospital and Research Centre, Mumbai,
India Lynn Riddell frcp, Clinical Director and Consultant
Ingrid Lizarraga mbbs, Clinical Assistant Professor of Physician, Integrated Sexual Health Services,
Surgery, Division of Surgical Oncology and Endocrine Northamptonshire Healthcare NHS Foundation Trust,
Surgery, University of Iowa Carver College of Medicine, Northampton, UK
IA, USA Bernard H. Sagherian md, Instructor of Clinical Surgery,
John S. P. Lumley Emeritus Professor of Vascular Surgery, American University of Beirut Medical Center, Division
University of London; Past Council Member and of Orthopedic Surgery, Department of Surgery, Beirut,
Chairman of Primary Fellowship Examinations, Royal Lebanon
College of Surgeons of England, UK Carol E. H. Scott-Conner md phd, Emeritus Professor of
Karim Masrouha md, Orthopaedic Surgery Resident, Surgery, Division of Surgical Oncology and Endocrine
American University of Beirut Medical Center, Beirut,
Surgery, University of Iowa Carver College of Medicine,
Lebanon
Mira Merashli md, NIHR Leeds Musculoskeletal IA, USA
Biomedical Research Unit, Leeds Teaching Hospitals Pierre M. Sfeir md facs, Associate Professor of Clinical
NHS Trust, University of Leeds, Leeds, UK Surgery, Head, Division of Cardio-Thoracic Surgery,
Basant K. Misra mbbs ms (general surgery) mch Director, Residency Program Department of Surgery
­( n eurosurgery) d iplomate n ational b oard American University of Beirut Medical Center, Beirut,
­(neurosurgery), Consultant Neurosurgeon and Head, Lebanon
Department of Neurosurgery and Gamma Knife Arpit Sharma ms dnb dorl, Assistant Professor,
Radiosurgery, P. D. Hinduja National Hospital and Department of Otorhinolaryngology, Seth G. S. Medical
Medical Research Centre, Mumbai, India College and K. E. M Hospital, Mumbai, India
Ahmad Moukalled md, General Surgery Resident, Fawwaz R. Shaw md, Congenital Cardiac Surgery Fellow,
American University of Beirut Medical Center, Beirut, University of Washington, Seattle Children’s Hospital,
Lebanon Seattle, WA, USA
Kelly Morris mb, Northamptonshire Healthcare NHS Malini D. Sur md, Department of Surgery, Mount Sinai
Foundation Trust, Kettering, UK School of Medicine, New York, NY, USA
Maurice Murphy mrcpi, Consultant Physician, Barts Shivakumar Thiagarajan ms (ent) dnb ms (ent) dnb,
Health NHS Trust, London, UK Fellowship in Head and Neck Surgical Oncology,
Imad S. Nahle md, Chief Resident, Orthopaedic Surgery,
Assistant Professor, Department of Surgical Oncology,
American University of Beirut Medical Center, Beirut,
Malabar Cancer Centre, Kerala, India
Lebanon
Imad Uthman md mph frcp, Professor of Clinical
Sudhir V. Nair ms (general surgery) mch (head and
Medicine, Head, Division of Rheumatology, American
neck oncology), Associate Professor, Head and Neck
Service, Tata Memorial Centre, Mumbai, India University of Beirut Medical Center, Beirut, Lebanon
Deepa Nair ms dnb dorl, Associate Professor, Head AbhishekVaidya ms dnb, Assistant Professor, Head Neck
and Neck Surgical Oncology, Tata Memorial Centre, Surgical Oncology, DMIMS, Wardha, India
Mumbai, India Richa Vaish ms, Senior Resident, Head and Neck Surgical
Rabih Nayfe md, Department of Internal Medicine, Akron Oncology, Tata Memorial Centre, Mumbai, India
General Medical Center, Cleveland Clinic Affiliate, Sagar S.Vaishampayan mds (oral & maxillofacial surgery),
Akron, OH, USA Fellowship in Head & Neck Oncosurgery, Associate
Gouri Pantvaidya ms dnb mrcs, Associate Professor, Professor, Department of Maxillofacial Surgery,
Department of Head Neck Surgery, Tata Memorial MGM Medical University, Navi Mumbai, Maharashtra,
Hospital, Mumbai, India India

K17518_Book.indb 10 21/11/15 12:19 am

 Preface to the
19th edition

A complete history and full clinical examination are the foundation of excellence in clinical practice. It is therefore
essential that these modalities are retained at the core of undergraduate and postgraduate training, irrespective of
enormous technical and scientific advances and the competing demands from other disciplines.
These clinical principles have been the key elements of Hamilton Bailey’s Demonstrations of Physical Signs since its first
publication in 1927. The ease of world travel has facilitated the rapid spread of infection, while chronic conditions such
as obesity, diabetes, cardiovascular conditions and many cancers are increasingly prevalent internationally, and clinicians
have to be aware of this in their differential diagnoses. The current edition reflects this global nature of disease in its
choice of editors and contributors from across the world.
Although Hamilton Bailey and his wife Vita would not recognise the current edition, they would appreciate its aims
for clarity of text and full colour illustration. Its system-based organization mirrors the structure of the current edition of
Bailey & Love’s Short Practice of Surgery, re-establishing the link between these two seminal surgical textbooks. We hope
that the nineteenth edition will continue to provide an invaluable source of clinical information for students worldwide.

John Lumley on behalf of the editorial team

London, 2015

K17518_Book.indb 11 21/11/15 12:19 am

This page intentionally left blank
 PART

1
Principles
1 History-taking and general examination

2 Distinctive clinical syndromes

3 Lumps, ulcers, sinuses and fistulas

4 Inflammation

5 HIV and AIDS

K17518_Book.indb 1 21/11/15 12:19 am

This page intentionally left blank
 CHAPTER History-taking and
1 General Examination
John S. P. Lumley and Natalie Anne Hirst

LEARNING OBJECTIVES

• To be able to take a concise, structured patient • To be able to undertake a focused examination

history of systems and a formulation of initial working
• To understand the basis for a systematic general diagnoses
examination of the patient • To be aware of the specific requirements of the
• To know the methods for taking a manual blood neonate and child in the surgical examination
pressure reading

HISTORY-TAKING symptomatic treatment. This strategy is based on the nature and

duration of the symptoms. It allays the patient’s fears and avoids
A patient usually comes to see a doctor with a specific problem an overinvestigation of trivial and self-limiting disease.
(a symptom) and the doctor’s aim is to make the patient ­better. A decision must be made, however, on whether the patient
To do this, the doctor tries to work out what is causing the needs to be seen again for further assessment. Continual expla-
problem (the diagnosis), determine its severity (assessment)
­ nation to the patient and good patient rapport are of vital
and then institute appropriate treatment. The total process of importance and will translate into a more accurate diagnosis and
­assessment and treatment is termed ‘management’. increased patient knowledge. Management occasionally has to be
Disease may be due to social and psychological as well as initiated before a definitive diagnosis has been made, such as in
physical abnormalities – the surgeon must be aware of, and sen- the control of severe pain or haemorrhage.
sitive to, all of these factors. To diagnose and assess a patient’s The following scheme for history-taking is intended as an
problems, the doctor can obtain information from three sources: introduction to the subject and outlines the prime headings that
• taking a history; need to be considered when interviewing each patient.
• carrying out a physical examination;
• requesting appropriate investigations.
SCHEME FOR HISTORY-TAKING
The history is the single most important factor in making a
First record the date and time of the examination. Note the

PRINCIPLES
diagnosis. Although this textbook is primarily concerned with
eliciting abnormal physical signs, these are not always present patient’s name, age, sex, occupation (past and present) and who
at the time a patient presents. The history directs the clinician they live with at home (including any dependants). The history
to search for the physical abnormalities and find them at the emerges from the patient’s description of the problem, directed by
earliest possible stage of the disease, thus facilitating further your planned questioning. It is conveniently recorded under the
management. following six headings.
The skilled clinician becomes an expert on the pattern of
|

Present Illness
diseases, but their greatest skill is to listen to what the patient
PART 1

volunteers. This is the key to the diagnosis and the clinician must Presenting Complaint(s)
not shape, elaborate, flavour or direct a history into a particular ‘Can you tell me why you’ve attended the hospital today?’ This
category just so that it fits a classical package. Such prompting must be put in a short statement, preferably using the patient’s
may result in misdiagnosis. own words, for example ‘c/o [complaining of] abdominal pain and
Sometimes it is not possible to make a diagnosis. However, vomiting for the last 24 hours’ or ‘increasing breathlessness for
the process of assessment serves to exclude serious abnormali- 2 weeks’. If there is more than one complaint, these are listed and
ties, allowing the clinician to reassure the patient and advise then taken in turn through the following two sections.

K17518_Book.indb 3 21/11/15 12:19 am

 4 H I S T O R Y- TA K I N G A N D G E N E R A L E X A M I N AT I O N

History of Presenting Complaint(s) Family History

This should record the details of each problem, using mainly Enquire into the state of health or cause of death of the patient’s
the patient’s own words. Record as accurately as possible how parents, siblings, other close relatives and partner. Ask whether
long the complaint has been present and include the sequence any members of the family are suffering, or have suffered, from the
of events in chronological order with dates (e.g. 1 year ago, presenting condition(s). It often helps to draw a family tree.
1 month ago, yesterday). Let the patient begin by telling the story
in their own words without interruption. Afterwards, ask specific Review of Systems
­questions using terms readily understood by the patient, either The history of the presenting complaint encompasses a detailed
enlarging upon or clarifying their symptoms. enquiry into at least one of the body’s systems; this part of the
The presenting disorder is usually related to one system, and history reviews the remaining systems for unsuspected abnor-
questions referable to this – and any other system involved in malities. It is carried out using specific questioning pertinent to
the presenting complaint – are delivered at this stage. Pain is each system, and this is then considered alongside the examina-
one of the most common symptoms; appropriate questions are tion of the relevant system. Important non-specific symptoms
given below. Many of these questions can also be applied to other may also be present such as fever, lassitude, malaise and weight
symptoms. change.
If the patient is a poor historian or is unable to give a history,
or you suspect them of giving unreliable information, it may be
helpful to talk to relatives or witnesses. Record the source of this PAIN
and all aspects of the history that are not obtained directly from
Pain is an indicator of disease and is frequently the presenting
the patient.
symptom for every body system. It varies with the disease process
Previous History of Presenting Complaint(s) and the tissue involved and may be characteristic and diagnostic.
Pain may be present at the time of interview but – although this
If the patient has had similar symptoms in the past, obtain
allows a first-hand experience of the patient’s problem – it can
detailed information in chronological order, including any treat-
also interfere with the assessment.
ment received and the results of any investigations (if known).
Pain is very subjective and can be influenced by what the
Report any past event with a clear bearing on the present condi-
patient thinks or suspects its cause to be and by its implications.
tion, such as operations, trauma, weight loss, medication, contact
Patients may have worries about the seriousness of a certain
with others with disease or any recent travel abroad.
condition and because relatives or friends have been disabled
Past Medical History by or died from similar problems. They may want to impress or
convince the doctor, or may underplay the symptom in order not
Note all other previous non-trivial illnesses, operations, accidents
to interfere with their own plans and needs. Responses to pain
and periods of admission to hospital for non-related illnesses,
also vary with age, sex, ethnic origin, education and personality.
together with their dates. For children, note illnesses, investi-
A doctor should guard against categorizing and interpreting a
gations and immunizations. In adults, note relevant childhood
pain to suit a chosen diagnosis and – even if leading questions are
problems, for example chronic respiratory disease, cardiac prob-
needed – there must be a free choice of answers.
lems and rheumatic fever.
Although friends and relatives can provide a good indication
Drugs and Allergies of how the pain is interfering with the patient’s everyday activi-
ties, they cannot describe the features of the pain. In this respect,
Note all drugs being taken, their doses and for how long they
the use of interpreters can be difficult since the words used
have been taken. Ask what drugs have been taken in the past and
to describe the nature and severity of pain may have different
for what conditions. Ensure that non-prescription medications,
meanings in different languages – the interpreter may be giving
for example St John’s Wort, and any other drugs the patient may
their own opinion rather than the patient’s. In addition, patients
not consider as medication, such as the oral contraceptive pill,
may be unwilling to admit their fears or disclose the precipitating
are also documented. Record drug allergies and any allergic symp-
causes of a pain via an interpreter.
toms. Ask what is meant by any admitted allergy or sensitivity.
Each doctor must therefore develop an efficient and reliable
PRINCIPLES

Social and Personal History method of questioning a patient about their pain, using clear,
understandable language. The following section outlines the
Note any current smoking habit, the number of years smoked
areas that need to be covered. It is worth studying these questions
and any changes over this time. Note the usual alcohol consump-
and reshuffling them into a form that you can easily remember,
tion in units per day or per week and what is drunk. Sensitively
perhaps converting them into an acronym or an anagram –
question whether the subject has ever been a heavy drinker. Ask
SOCRATES is a well-known example:
|

whether any recreational drugs are used, which drugs, when and
in what quantities. • S: Site;
PART 1

Record details of the patient’s work and, where relevant, any • O: Onset;
difficulties with their job, family or finances. Note any recent • C: Character;
mental stress or problems with their sleeping pattern. Does the • R: Radiation;
patient live alone? Which floor? Are there lifts? Is the lavatory • A: Associations;
on a different floor? Are friends and/or relatives nearby? Do they • T: Timing;
receive or need home help or meals on wheels? Will the patient • E: Exacerbating/relieving factors;
be able to return to their previous residence and/or employment? • S: Severity.

K17518_Book.indb 4 21/11/15 12:19 am

 Pain 5

Site large bowel or a stone blocking the ureter. Note how often these
The site of the pain is a good indicator of its origin. Ask the attacks occur and their duration. The pain may be continuous
patient where the pain is, and get them to point to the area of with exacerbations producing peaks of pain. Factors exacerbating
maximum intensity. This may be focal and indicated with one or precipitating the pain are considered below (see ‘Modification’,
finger, such as an infected maxillary air sinus or a fractured lateral below).
malleolus. Injuries in particular can usually be localized by the Enquire carefully about previous bouts of pain or anything
site of the pain and tenderness – pain is what is experienced by similar in the past. Record the patterns of previous attacks, their
the patient, while tenderness is elicited by the examining doctor. frequency, how many there have been in all and their duration.
Pain arising from the skin and subcutaneous tissues is better Note whether they are changing in character. The terms ‘exacer-
localized than that from deeper structures as pain in the latter bation’ and ‘recurrence’ are used to denote changes in a disease
may be diffuse. Headache from an intracranial lesion may be as well as in its symptoms.
indicated by the patient placing a whole hand placed over the Like the onset, the offset of pain may be gradual or sudden,
side or top of the head. Similarly, cardiac pain may be demon- and this may be characteristic of the condition. Relief of the pain
strated by a hand over the central chest wall, and abdominal pain usually indicates an improvement in the disease or a removal of
by a hand over a quadrant of the abdomen. Severe limb ischaemia the precipitating cause. Improvement may be obtained by treat-
is another example of diffuse pain, with the rest pain involving ing the patient with analgesics, surgically or with other therapies.
the forefoot or sometimes the whole foot and lower leg. Very occasionally, a reduction of pain is a bad sign, for example
Pain may radiate from the site of origin to another region of with the rupture of a tense abscess into the cerebral ventricles or
the body; for example, protrusion of an intervertebral disc may the peritoneal cavity. The previous history and a knowledge of
trap a nerve, giving local back pain, but may also produce pain any underlying disease can provide guidelines on the likelihood
down the back of the thigh and possibly into the calf or foot. Pain of a further recurrence of the pain.
from posterior abdominal wall structures – such as the pancreas
and abdominal aorta – may radiate through to the back. Renal Severity
colic may radiate from the loin around to the iliac fossa and into The quantity of pain is generally related to the severity of the
the groin. Gallbladder pain may be felt between the shoulder underlying disease. However, individuals vary extensively in their
blades, while the pain of a myocardial infarction may radiate from pain tolerance, and this is further influenced by anxiety and a fear
the chest into the neck and down the left arm. The radiated pain of the possible implications of the pain. Sometimes there may be
may have different features from the local pain and may occur a desire to impress the doctor over the extent of the problem or
independently of it. conversely to play down the symptoms for some personal reason.
Referred pain implies pain occurring at a site far removed A useful indicator is the influence of the pain on the patient’s
from the originating disease. It is due to visceral nerve impulses lifestyle. Ask whether they have had to stop work or go to bed
stimulating the somatic afferent pathways of the same dermat- and whether they are losing sleep because of the pain. If they
ome. A classic example is pain over the tip of the shoulder from have pain at the time of the interview, their response to it can
disease under the diaphragm, the visceral nerve involved being be directly assessed. However, by this time they may already have
the phrenic, and the somatic dermatome the fourth cervical. had some appropriate analgesia.
A rough quantitative measure can be obtained using a pain
Timing scale of 0 to 10. The patient is asked to grade their pain on this
When asking about the timing of a pain, include its onset, pro- scale, with 0 being no pain at all and 10 being the worst pos-
gress and offset. The onset may be sudden or gradual. Sudden sible pain imaginable. Although this is still very subjective and
pain is typical of pain associated with an injury or with the dependent on the individual’s response, it can be of value in
blockage or rupture of an artery (as in myocardial infarction or assessing change within the individual.
a ruptured abdominal aorta) or the rupture of a viscus (such as
a spontaneous pneumothorax or a perforated peptic ulcer). Most Character
patients are be able to describe the precise time of onset in these The character or quality of the pain is another subjective assess-
examples. ment; it may have specific characteristics but these may be dif-

PRINCIPLES
With a gradual onset, the timing may vary greatly. Acute ficult to categorize. The terms used can be linked to previous
inflammatory lesions may progress during a day or overnight, experiences – common descriptions are sharp, stabbing or knife-
while claudication from degenerative arterial disease or the pain like. Such terms are associated with most wounds.
of an osteoarthritic knee may build up over many years before the Inflammation and pain from deeper organs are often described
patient realizes that a vague ache is a specific problem and seeks in less precise terms, such as aching, bruising, burning, gripping,
medical advice. ‘Gradual’ in these examples implies a gradual crushing, twisting and breaking. Colic has already been referred
|

awareness of the pain; it also indicates a gradual increase in the to above for gut obstruction, when the patient may also complain
severity of the pain. of a distended or bloated feeling; this may also occur in childbirth
PART 1

Note the progress of the current attack, whether it is changing and urinary retention.
and whether there is any pattern to the pain. Pain may gradually A throbbing pain implies a tense, sensitive area with an
increase or decrease or become continuous or persistent. It may increase in tension with each heart beat. Such situations can
also fluctuate. There may be total relief from the pain between occur with vascular tumours, acute inflammation with or without
bouts. The latter is characteristic of colic, which is due to waves an abscess, and raised intracranial pressure and vascular lesions
of contraction down an obstructed hollow viscus, such as with such as an expanding aneurysm or a complicated arteriovenous
adhesions obstructing the small bowel, a cancer obstructing the malformation or fistula.

K17518_Book.indb 5 21/11/15 12:19 am

 6 H I S T O R Y- TA K I N G A N D G E N E R A L E X A M I N AT I O N

Modification minimal discomfort and inconvenience. A warm environment

Some of the factors that precipitate and influence a pain may is essential and, similarly, the examiner’s hands must be warm.
have already been elicited by this stage in the history. Now ask The privacy of a small room or a curtained area is desirable, with
the patient specifically what makes the pain worse or better, and optimal, preferably natural, lighting.
what they do in an attack. The patient should undress down to their underclothes and
Aggravating/exacerbating factors include eating spicy foods put on a dressing gown. They will then lie supine on a couch
(for peptic ulcers) and fatty foods (with biliary disease), move- with an adjustable back to provide head support, covered with
ment such as coughing (for pleuritic pain and pain due to peri- a sheet or blanket. Each area must be adequately exposed as
tonitis) or walking (with lower limb injuries or ischaemia), and needed without embarrassing the patient. A cardinal principle is
certain postures such as sitting and standing (with lumbar disc to expose both sides when examining paired structures in order
protrusions) and raising the leg (in severe foot ischaemia or sacral to compare the diseased with the normal, for example a limb
nerve root compression). or breast. A chaperone may be appropriate when examining
Relieving factors include analgesics and specific medications members of the opposite sex. Relatives are usually best excluded,
such as antacids. Eating may relieve the pain of duodenal ulcers, except when examining children.
and resting a limb may ease the inflammatory pain and pain The examiner stands on the right side of the patient. The
caused by an injury. The severe pain of lower limb ischaemia may order of examination is regional rather than by system, although
be helped by hanging the leg out of bed. the central nervous system is often examined as an entity,
The application of heat from a hot flannel, a fire or a hot water together with various parts of the locomotor system, at the end
bottle is often used, and specific aids such as transcutaneous of the procedure.
electrical nerve stimulation can help. The repeated use of heat It is usual to start the examination with the patient’s hands
such as a fire to the shins or a hot water bottle on the abdomen and then to proceed methodically from head to toe, surveying
may produce a characteristic mottled brown skin pigmentation all the systems and later integrating these findings, as subsequent
(erythema ab igne), providing an important physical sign. verbal presentations and recordings in the notes are usually
Remember that denervation may render an area insensitive by system. Thoroughness is important – efficiency and speed
and therefore subject to repeated trauma and inflammatory develop with practice. The examination time should not be
changes without the protective benefit of pain sensation. Such prolonged for ill or frail patients, and in emergencies it may be
examples are seen in diabetic neuropathy, where perforating appropriate to concentrate on diseased areas, completing the
ulcers are commonly seen over the pressure areas of the sole. routine examination at a later time.
Extreme examples are seen in leprosy, where there can be a pro-
gressive loss of digits and limbs.
General Impression
Throughout the history-taking, the clinician is gaining an impres-
Associated Symptoms sion of the patient’s physical and mental status and the severity
The systemic effects of pain may be primary or secondary. Primary of their disability, as well as attempting to make a diagnosis. The
effects are specific events such as the vomiting that is seen with physical examination continues these observations, giving infor-
peptic ulcers and the diarrhoea of inflammatory bowel disease. mation on the patient’s general state of health, shape, posture,
However, these same symptoms can be seen as non-specific state of hygiene and mental and physical activity. The patient must
effects in severe pain originating outside the alimentary tract. be considered as a whole but initially the doctor should observe
Similarly, nausea, malaise, sweating, loss of sleep and restricted the exposed parts, particularly the hands, skin, head and neck.
fluid and food intake are frequently encountered. It is of para- The patient may be fit and well, but problems with diet and
mount importance to ascertain any weight loss due to its frequent disease can lead to an alteration in nutrition and hydration such
correlation with malignancy. Attempts should be made to quan- as obesity, weight loss, cachexia, loss of skin turgor or skin laxity.
tify this, either by a change in the patient’s weight on measuring In the clinic, it is important to weigh the patient; other factors
scales or in terms of whether the patient has noticed their cloth- that should be routinely charted are the pulse rate, blood pressure
ing getting looser. and urine test results. A subject can usually state their height,
but an accurate assessment, together with measurements of seg-
Cause of Pain
PRINCIPLES

ments and spans, may be important when considering endocrine

It is important to ask the patient’s opinion on the cause of their abnormalities. Admission to hospital usually indicates more
pain as they may know or think they know what this is. They may severe disease states, and additional monitoring then includes
be afraid or unwilling to tell you the cause as there may be a guilt temperature, respiratory rate, bowel habit and the examination
complex, such as with current or previous self-abuse, but there of the sputum and faeces.
may still be some hints on the underlying cause of the pain. Such
Mental Status
|

clues must be carefully noted. The patient may well have given
a lot of thought to the potential causes of their pain, and it is A patient’s behaviour may be influenced by the unaccustomed
PART 1

important to identify areas of anxiety, which can often be treated situation of being a patient or by the effect of the disease, particu-
by immediate reassurance. larly if there is pain. This may be manifest by the patient’s facial
expression, the degree of eye contact, restlessness, sweating, anxi-
GENERAL PHYSICAL EXAMINATION ety, apathy, depression, lack of cooperation or aggression. Stress
may be indicated by rapid respiration, a rapid pulse rate and
When undertaking a physical examination, aim to keep the sweating. Note whether the patient’s comprehension and acuity
patient comfortable, relaxed and reassured. Talk through what equate to what one would expect from the history, or whether
is going to happen – if this is not obvious – and ensure there is this could have changed in relation to the disease.

K17518_Book.indb 6 21/11/15 12:19 am

 General Physical Examination 7

Drugs, head injuries and other diseases of the central ­nervous

system can affect the level of consciousness, varying through (a)
alert, slow and confused, lacking concentration and a reduced
level of response to spoken and physical stimuli. The patient’s
orientation in time, place and person should be noted: the
­
Glasgow Coma Scale (see p. 140, Table 6.2) is a valuable way of
documenting the level of consciousness for serial measurement.
A patient’s speech may be impaired by diseases of the central
nervous system, producing dysphasia or dysarthria, and there
may be voice changes such as hoarseness in laryngeal infection or
myxoedema. Impairment of motor function can produce weak-
ness or spasticity, and this may affect the speech.
The posture and gait should be noted, as should the ability to
perform other activities such as undressing. There may be added
movements such as the fine tremors of age, thyrotoxicosis, par-
kinsonism and alcoholism, the flapping tremors of hepatic, res- (b)
piratory, renal and cardiac failure, or more specific neurological
abnormalities producing a lack of coordination and involuntary
movements.
Psychiatric assessment is not usually part of a surgical exami-
nation, but if abnormalities are present or suspected, note the
general behaviour and any disturbances of consciousness and ori-
entation. Record the patient’s emotional state, insight, thought
processes and content, as well as any hallucinations, delusions
and compulsive phenomena, and include an assessment of cogni-
tive and intellectual function.

Abnormal Facies and Body Configuration

Figure 1.1 The acromegalic hand is large with wide long fingers.
A number of congenital and endocrine diseases have character-
istic general features amenable to a spot diagnosis. However, one
needs experience to differentiate between minor changes and
the extremes of normality so be aware of the danger of jumping
to false conclusions. Congenital examples are Down, Turner’s
and Marfan’s syndromes, achondroplasia and hereditary telangi-
ectasia. Endocrine abnormalities include acromegaly, Cushing’s
disease, myxoedema and thyrotoxicosis. Other spot diagnoses
included are Paget’s disease, parkinsonism and myopathies (see
Chapters 2 and 18). Some general disease states can be found
in Chapter 2 and include weight loss, dehydration, oedema and
pyrexia of unknown origin, as well as examples from the above
list. Other examples included elsewhere are the features of
hepatic and renal failure.

The Hands Figure 1.2 Skin pigmentation of the dorsum of the hand in a white
patient with Nelson’s syndrome.
The general examination starts with the patient’s hands: sweat-

PRINCIPLES
ing or abnormal soft tissue may have been noted during the
introductory handshake. The hand may be unusually large, as in
acromegaly (Figure 1.1), or small or deformed, perhaps relating
to a previous injury or to systemic disease. Skin abnormalities of
the palm and dorsum of the hand may be easier to see in a white-
skinned individual but are usually visible in all races and should
|

be carefully noted. They include pallor, cyanosis, polycythaemia,

pigmentation (Figure 1.2), bruises, rashes (Figures 1.3 and 1.4)
PART 1

and nicotine stains (Figure 1.5). Many of these features are more
easily seen in the head and neck, and are further considered in
the next section.

Nails
The nails can be an indicator of local and systemic disease. There
can be stunted growth, and they may be brittle and deformed. Figure 1.3 Hyperpigmentation of an area of atopic eczema on the wrist
Nail-biters can be identified from the loss of the projecting of a patient with Addison’s disease.

K17518_Book.indb 7 21/11/15 12:19 am

Exploring the Variety of Random
Documents with Different Content
 Biochemistry - Field Notes
Fall 2021 - Center

Prepared by: Prof. Jones

Date: August 12, 2025

Chapter 1: Practical applications and examples

Learning Objective 1: Assessment criteria and rubrics
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 1: Diagram/Chart/Graph]
Learning Objective 2: Theoretical framework and methodology
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 3: Statistical analysis and interpretation
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 4: Research findings and conclusions
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 5: Current trends and future directions
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 5: Theoretical framework and methodology
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 6: Diagram/Chart/Graph]
Example 6: Study tips and learning strategies
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Theoretical framework and methodology
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Learning outcomes and objectives
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Remember: Comparative analysis and synthesis
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Background 2: Fundamental concepts and principles
Important: Research findings and conclusions
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Interdisciplinary approaches
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Key Concept: Literature review and discussion
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Study tips and learning strategies
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Key terms and definitions
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Theoretical framework and methodology
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 16: Critical analysis and evaluation
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Problem-solving strategies and techniques
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 18: Ethical considerations and implications
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Problem-solving strategies and techniques
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Results 3: Statistical analysis and interpretation
Practice Problem 20: Interdisciplinary approaches
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Research findings and conclusions
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Comparative analysis and synthesis
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 23: Problem-solving strategies and techniques
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Study tips and learning strategies
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 25: Research findings and conclusions
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Assessment criteria and rubrics
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 27: Assessment criteria and rubrics
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Best practices and recommendations
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Comparative analysis and synthesis
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice 4: Interdisciplinary approaches
Example 30: Current trends and future directions
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 31: Practical applications and examples
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Best practices and recommendations
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Key terms and definitions
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Comparative analysis and synthesis
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Critical analysis and evaluation
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 36: Diagram/Chart/Graph]
Important: Interdisciplinary approaches
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 37: Problem-solving strategies and techniques
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Comparative analysis and synthesis
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 39: Best practices and recommendations
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Quiz 5: Experimental procedures and results
Important: Comparative analysis and synthesis
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 41: Diagram/Chart/Graph]
Remember: Critical analysis and evaluation
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Literature review and discussion
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Case studies and real-world applications
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Example 44: Best practices and recommendations
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Case studies and real-world applications
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 46: Learning outcomes and objectives
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Comparative analysis and synthesis
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Important: Theoretical framework and methodology
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Best practices and recommendations
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Discussion 6: Current trends and future directions
Example 50: Fundamental concepts and principles
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 51: Diagram/Chart/Graph]
Note: Study tips and learning strategies
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Problem-solving strategies and techniques
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Important: Statistical analysis and interpretation
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Statistical analysis and interpretation
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Study tips and learning strategies
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Practical applications and examples
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 57: Ethical considerations and implications
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Fundamental concepts and principles
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Learning outcomes and objectives
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Results 7: Fundamental concepts and principles
Note: Theoretical framework and methodology
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 61: Diagram/Chart/Graph]
Example 61: Current trends and future directions
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 62: Case studies and real-world applications
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Definition: Fundamental concepts and principles
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Key terms and definitions
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Critical analysis and evaluation
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 66: Practical applications and examples
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 67: Diagram/Chart/Graph]
Important: Statistical analysis and interpretation
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Learning outcomes and objectives
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 69: Problem-solving strategies and techniques
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Test 8: Problem-solving strategies and techniques
Remember: Current trends and future directions
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 71: Experimental procedures and results
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 72: Diagram/Chart/Graph]
Example 72: Literature review and discussion
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Critical analysis and evaluation
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Note: Statistical analysis and interpretation
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 75: Diagram/Chart/Graph]
Key Concept: Historical development and evolution
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
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