DIAGNOSTIC EXAMINATION - Quality Improvement Organizations

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DeGowin’sDIAGNOSTICEXAMINATIONNinth EditionRichard F. LeBlond, MD, MACPProfessor of Internal Medicine (Clinical)The University of Iowa College of MedicineIowa City, IowaRichard L. DeGowin, MD, FACPProfessor Emeritus of Internal MedicineThe University of Iowa College of MedicineIowa City, IowaDonald D. Brown, MD, FACPProfessor of Internal MedicineThe University of Iowa College of MedicineIowa City, IowaIllustrated byElmer DeGowin, MD,Jim Abel,and Shawn RoachNew York Chicago San FranciscoLisbon London Madrid Mexico City MilanNew Delhi San Juan Seoul Singapore Sydney Toronto

CONTENTSxxixxvxxviiPrefaceCommon AbreviationsIntroduction and User’s GuidePART ITHE DIAGNOSTIC FRAMEWORK1. Diagnosis21. Why is Diagnosis Important?2. Diseases and Syndromes: Communication and Entry tothe Medical LiteratureA. The Diagnostic Examination1. Stories: Listen, Examine, Interpret, Explain2. Finding Clues to the Diagnosis3. Select Hypotheses: Generate a DifferentialDiagnosis4. Cognitive Tests of the Diagnostic Hypotheses5. Selection of Diagnostic Tests6. Rare Diseases7. Certainty and Diagnosis8. Prognostic Uncertainty9. Deferred Diagnoses10. A Summary of the Diagnostic Process11. Caveat12. An Example of the Diagnostic ProcessB. Other Examinations1. The Autopsy2. Other Varieties of Medical Examinations2. History Taking and the Medical RecordA. Outline of the Medical RecordB. Procedure for Taking a History1. Definition of the Medical Historyix223345891010101111121313131415151616

xContents2. Scope of the History3. Methods in History Taking4. Conducting the InterviewC. Completion of the Medical Record1. Identification2. The Informant3. Chief Complaints (CC)4. History of Present Illness (HPI)5. Past Medical and Surgical History6. Family History (FH)7. Social History (SH)8. Review of Systems (ROS)9. Medications10. Allergies and Medication Intolerances11. Preventive Care Services12. Advance Directives13. Physical Examination (PE)14. Laboratory15. Assessment16. The PlanD. The Oral PresentationE. Other Clinical Notes1. Inpatient Progress Notes2. Off-Service Note3. Discharge Summary4. Clinic NotesF. The Patient’s Medical Record1. Purposes2. Physician’s Signature3. Custody of the RecordG. Electronic Medical Records3. The Screening Physical ExaminationA. Methods for Physical Examination1. Inspection2. Palpation3. Percussion4. AuscultationB. Procedure for the Screening Physical Examination1. Preparing for the Screening Examination2. Performance of the Screening 93030303030313131323232343535363840414244

ContentsxiPART IITHE DIAGNOSTIC EXAMINATIONThe Diagnostic Examination: Chapters 4 to 164. Vital Signs, Anthropometric Data, and PainA. Vital Signs1. Body Temperature2. The Pulse: Rate, Volume, and Rhythm3. Respirations: Respiratory Rate and Pattern4. Blood Pressure and Pulse PressureB. Anthropometric Data1. Height2. WeightC. Pain1. Diagnostic Attributes of Pain2. Pain Syndromes5. Non-Regional Systems and DiseasesA. Constitutional SymptomsB. The Immune System1. Two Common SyndromesC. The Lymphatic System1. Examination of the Lymph Nodes2. Lymph Node Signs3. Lymph Node SyndromesD. The Hematopoietic System and Hemostasis1. Red Blood Cell (Erythrocyte) Disorders2. Neutrophil Disorders3. Myeloproliferative Disorders and Acute Leukemia4. Platelet Disorders5. Coagulation DisordersE. The Endocrine System1. Diabetes and Hypoglycemia2. Disorders of Thyroid Function3. Disorders of Adrenal Function4. Disorders of Parathyroid Function5. Disorders of Pituitary Function6. The Skin and NailsA. Physiology of the Skin and 103104105106107108108109112113113115115

xiiContentsB. Functional Anatomy of the Skin and Nails1. Epidermis2. Dermis and Subcutaneous Tissue3. The Fingernails4. The Toenails5. Skin Coloration6. Hair7. Sebaceous Glands8. Eccrine (Sweat) Glands9. Apocrine Glands10. Nerves11. Circulation of the Skin and Mucosa12. Cutaneous Wound Healing and RepairC. Examination of the Skin and NailsD. Skin and Nail SymptomsE. Skin and Nail Signs1. Anatomic Distribution of Lesions2. Pattern of Lesions3. Morphology of Individual Lesions4. Generalized Skin Signs5. Changes in the Hair6. Fingernail Signs7. Arterial Circulation Signs8. Purpura9. Non-Purpuric Vascular LesionsF. Common Skin and Nail Syndromes1. Common Skin Disorders2. Skin Infections and Infestations3. Bullous Skin Diseases4. Skin Manifestations of Systemic Diseases5. Vascular Disorders6. Skin Neoplasms7. The Head and NeckA. Major Systems of the Head and NeckB. Functional Anatomy of the Head and Neck1. The Scalp and Skull2. The Face and Neck3. The Ears4. The Eyes5. The Nose6. The Mouth and Oral Cavity7. The 74178178179179180180181187188190

Contents8. The Salivary Glands9. The Thyroid GlandC. Physical Examination of the Head and Neck1. Examination of the Scalp, Face, and Skull2. Examination of the Ears, Hearing, and LabyrinthineFunction3. Examination of the Eyes, Visual Fields andVisual Acuity4. Examination of the Nose and Sinuses5. Examination of the Lips, Mouth, Teeth, Tongue,and Pharynx6. Examination of the Larynx7. Examination of the Salivary Glands8. Examination of the Temporomandibular Joint9. Examination of the Neck10. Examination of the Lymph Nodes11. Examination of the Vascular SystemD. Head and Neck Symptoms1. General Symptoms2. Skull, Scalp, and Face Symptoms3. Ear Symptoms4. Eye Symptoms5. Nose Symptoms6. Lip, Mouth, Tongue, Teeth, and PharynxSymptoms7. Larynx Symptoms8. Salivary Gland Symptoms9. Neck SymptomsE. Head and Neck Signs1. Scalp, Face, Skull, and Jaw Signs2. Ear Signs3. Eye Signs4. Nose and Sinus Signs5. Lip Mouth, Teeth, Tongue and Pharynx Signs6. Larynx and Trachea Signs7. Salivary Gland Signs8. Neck Signs9. Thyroid SignsF. Head and Neck Syndromes1. Scalp, Face, Skull, and Jaw Syndromes2. Eye Syndromes3. Ear Syndromes4. Nose and Sinus 258272274275279280280282284288

xivContents5. Oral Syndromes (Lips, Mouth, Tongue, Teeth, andPharynx)6. Larynx Syndromes7. Salivary Gland Syndromes8. Thyroid Goiters and Nodules8. The Chest: Chest Wall, Pulmonary, and CardiovascularSystems; The BreastsSECTION 1Chest Wall, Pulmonary, and Cardiovascular SystemsA. Major Systems and Physiology1. The Thoracic Wall2. The Lungs and Pleura3. The Cardiovascular SystemB. Superficial Thoracic Anatomy1. The Chest Wall2. The Lungs and Pleura3. The Heart and PrecordiumC. Physical Examination of the Chest and Major Vessels1. Examination of the Rib Cage and Thoracic Musculature2. Examination of the Lungs and Pleura3. Examination of the Cardiovascular SystemD. Chest, Cardiovascular and Respiratory Symptoms1. General Symptoms2. Chest Wall Symptoms3. Lung and Pleural Symptoms4. Cardiovascular SymptomsE. Chest, Cardiovascular and Respiratory Signs1. Chest Wall Signs2. Lung, Pleura, and Respiratory Signs3. Cardiovascular Signs4. Mid-Precordial Systolic Murmurs5. Apical Systolic Murmurs6. Basal Diastolic Murmurs7. Mid-Precordial Diastolic Murmur8. Apical Diastolic Murmurs9. Pulse Contour10. Pulse Volume11. Arterial Sounds12. Venous Signs of Cardiac ActionF. Chest, Cardiovascular and Respiratory Syndromes1. Chest Wall 79380382383385385388388

Contents2. SyndromesCardiovascular SyndromesMyocardial Ischemia Six-Dermatome Pain SyndromesInflammatory Six-Dermatome Pain SyndromesMediastinal and Vascular Six-Dermatome PainSyndromes7. Gastrointestinal Six-Dermatome Pain Syndromes8. Pulmonary Six-Dermatome Pain SyndromesSECTION 2The BreastsA. Breast Physiology1. The Female Breast2. The Male BreastB. Superficial Anatomy of the BreastsC. Physical Examination of the Breasts1. Breast Examination2. Nipple ExaminationD. Breast SymptomsE. Breast SignsF. Breast Syndromes1. The Female Breast2. The Male Breast9. The Abdomen, Perineum, Anus, and RectosigmoidA. Major Systems and Their Physiology1. Alimentary System2. Hepatobiliary and Pancreatic System3. Spleen and Lymphatics4. Kidneys, Ureters, and BladderB. Superficial Anatomy of the Abdomen and Perineum1. The Abdomen2. The Anus3. The Rectum4. The Sigmoid and Descending ColonC. Physical Examination of the Abdomen1. The Abdomen2. Examination of the Perineum, Anus, Rectum,and Distal Colon3. Examination of the Anus4. Examination of the Rectum5. Examination of the Sigmoid ColonD. Abdominal, Perineal and Anorectal 449449450459460460461462

xviContents1. General Symptoms2. Site-Attributable SymptomsE. Abdominal, Perineal and Anorectal Signs1. Abdominal Signs2. Perineal, Anal, and Rectal SignsF. Abdominal, Perineal and Anorectal Syndromes1. GI, Hepatobiliary and Pancreatic Syndromes2. Perineal, Anal, and Rectal Syndromes3. Occult GI Blood Loss10. The Urinary SystemA. Overview and Physiology of The Urinary SystemB. Anatomy of the Urinary SystemC. Physical Examination of the Urinary SystemD. Urinary System SymptomsE. Urinary System SignsF. Urinary System Syndromes11. The Female Genitalia and Reproductive SystemA. Overview of Female Reproductive PhysiologyB. Anatomy of the Female Genitalia and Reproductive SystemC. Physical Examination of the Female Genitalia andReproductive System1. The Female Pelvic ExaminationD. Female Genital and Reproductive Symptoms1. General Symptoms2. Vulvar and Vaginal SymptomsE. Female Genital and Reproductive Signs1. Vulvar Signs2. Vaginal Signs3. Cervical Signs4. Uterine Signs5. Adnexal Signs6. Rectal SignsF. Female Genital and Reproductive Syndromes12. The Male Genitalia and Reproductive SystemA. Overview of Male Reproductive PhysiologyB. Anatomy of the Male Reproductive System1. The Penis2. The 558563563563563564

Contents3. Testis, Epididymis, Vas Deferens, and SpermaticCord4. The Prostate and Seminal VesiclesC. Physical Examination of the Male Genitalia andReproductive System1. Examination of the Penis2. Examination of the Scrotum3. Examination of Scrotal Contents4. Examination for Scrotal Hernia5. Examination of the Testes6. Examination of the Epididymis7. Examination of the Spermatic Cord8. Examination of the Inguinal Regions for HerniaD. Male Genital and Reproductive SymptomsE. Male Genital and Reproductive Signs1. Penis Signs2. Urethral Signs3. Scrotum Signs4. Testis, Epididymis, and Other Intrascrotal Signs5. Prostate and Seminal Vesicle SignsF. Male Genital and Reproductive Syndromes13. The Spine, Pelvis and ExtremitiesA. Major Systems and Their Physiology1. Bones and Ligaments2. Joints3. Muscles, Tendons, and BursaeB. Superficial Anatomy of the Spine and Extremities1. The Axial Skeleton: Spine and Pelvis2. Appendicular Skeleton Including Joints, Ligaments,Tendons, and Soft TissuesC. Physical Examination of the Spine and Extremities1. Examination of the Axial Skeleton: Spine and Pelvis2. Examination of the Appendicular Skeleton IncludingJoints, Ligaments, Tendons, and Soft TissuesD. Musculoskeletal and Soft Tissue SymptomsE. Musculoskeletal and Soft Tissue Signs1. General Signs2. Axial Musculoskeletal Signs3. Appendicular Skeleton, Joint, Ligament, Tendon, andSoft-Tissue Signs4. Muscle 15619619621626662

xviiiContentsF. Musculoskeletal and Soft Tissue Syndromes1. General Syndromes2. Conditions Primarily Affecting Joints3. Conditions Primarily Affecting Bone4. Axial Skeleton: Spine and Pelvis Syndromes5. Appendicular Skeletal Syndromes (Including Joints,Tendons, Ligaments, and Soft Tissues)6. Muscle Syndromes14. The Neurologic ExaminationA. Overview of the Nervous System1. Anatomic Organization2. Functional Organization of the Nervous SystemB. Superficial Anatomy of the Nervous SystemC. The Neurologic Examination1. Cranial Nerve Examination2. Motor Examination3. Examination of Reflexes4. Posture, Balance, and Coordination:The Cerebellar Examination5. Testing Specific Peripheral Nerves6. Movements of Specific Muscles and NervesD. Neurologic Symptoms1. General Symptoms2. Cranial Nerve Symptoms3. Motor Symptoms4. Posture, Balance, and Coordination Symptoms5. Sensory SymptomsE. Neurologic Signs1. Cranial Nerve Signs2. Motor Signs3. Reflex Signs4. Posture, Balance, and Coordination Signs:Cerebellar Signs5. Sensory Signs6. Autonomic Nervous System Signs7. Some Peripheral Nerve SignsF. Neurologic Syndromes1. Falling2. Headache3. 5726727730730731739

Contents4. Impaired Consciousness5. Chronic Vegetative and Minimally ConsciousStates6. Cerebrovascular Syndromes7. Other CNS Syndromes8. Other Motor and Sensory Syndromes9. Disorders of Language and Speech10. Syndromes of Impaired Mentation11. Other Syndromes15. The Mental Status, Psychiatric, and Social Evaluationsxix741748748751755760761763766SECTION 1The Mental Status and Phychiatric EvaluationA. The Mental Status EvaluationB. Psychiatric Symptoms and Signs1. Abnormal Perception2. Abnormal Affect and Mood3. Abnormal Thinking4. Abnormal Memory5. Abnormal BehaviorsC. Psychiatric Syndromes1. Multiaxial Assessment2. Acute and Subacute Confusion3. Anxiety Disorders4. Disorders of Mood5. Personality Disorders6. Other Personality Disorders7. Thought Disorders8. Other 8780783784SECTION 2The Social EvaluationA. Evaluation of Social Function and RiskB. Common Social Syndromes and Problems784784785PART 3PREOPERATIVE EVALUATION16. The Preoperative EvaluationA. Introduction to Preoperative ScreeningB. The History788788788

xxContents1. Assessment of Cardiovascular and Pulmonary Riskfrom History2. Assessment of Bleeding Risk from History3. Assessment of Metabolic Risk: Diabetes, Renal, andHepatic Insufficiency4. Family History5. Medications6. Personal Habits7. Mechanical and Positioning RisksC. The Physical ExaminationD. Mental StatusE. Laboratory TestsF. Summative Risk Assessment789790790791791792792792793793794PART 4USE OF THE LABORATORY ANDDIAGNOSTIC IMAGING17. Principles of Diagnostic TestingA. Principles of Laboratory Testing1. Principles of Testing for Disease2. Aids in the Selection and Interpretation of Tests3. Examples4. 2 2 Tables Revisited: Caveat Emptor5. Rule In; Rule Out6. SummaryB. Principles of Diagnostic Imaging18. Common Laboratory TestsA. Blood ChemistriesB. Hematologic Data1. Blood Cells2. CoagulationC. UrinalysisD. Cerebrospinal FluidE. Serous Body 836837839840843

PREFACETo The Reader:Pray thee, take care, that tak’st my book in handTo read it well: that is to understand.—Ben JonsonFar beyond being a text describing how to perform a history and physical exam,DeGowin’s Diagnostic Examination is, uniquely, a text to assist clinicians in thinking about symptoms and physical signs to facilitate generation of reasonable,testable diagnostic hypotheses. The clinician’s goal in performing a history andphysical examination is to generate these diagnostic hypotheses. This was true forHippocrates and Osler and remains true today. The practice of medicine wouldbe simple if each symptom or sign indicated a single disease. There are enormousnumbers of symptoms and signs (we cover several hundred) and they can occurin a nearly infinite number of combinations and temporal patterns. These symptoms and signs are the rough fibers from which the clinician must weave a clinicalnarrative, anatomically and pathophysiologically explicit, forming the diagnostichypotheses. To master the diagnostic process, a clinician must have four essentialattributes:(1)(2)(3)(4)Knowledge: Familiarity with the pathophysiology, symptoms, and signs ofcommon and unusual diseases.Skill: The ability to take an accurate and complete history and performan appropriate physical examination to elicit the pattern of symptoms andsigns from each patient.Experience: Comprehensive experience with many diseases and patients,each thoroughly evaluated, allows the skilled clinician to generate a probabilistic differential diagnosis, a list of those diseases or conditions mostlikely to be causes of this patient’s illness.Judgment: Knowledge of medical science and the medical literature combined with experience reflected upon hones the judgment necessary toknow when and how to test these hypotheses with appropriate laboratorytests or clinical interventions [Reilly BM. Physical examination in the care ofmedical inpatients: an observational study. Lancet. 2003;362:1100–1105].DeGowin’s Diagnostic Examination has been used by students and clinicians forover 40 years precisely because of its usefulness in this diagnostic process:(1)(2)It describes the techniques for obtaining a complete history and performinga thorough physical examination.It links symptoms and signs with the pathophysiology of disease.xxi

xxii(3)(4)PrefaceIt presents an approach to differential diagnosis, based upon the pathophysiology of disease, which can be efficiently tested in the laboratory.It does all of this in a format that can be used as a quick reference at the“point of care” and as a text to study the principles and practice of historytaking and physical examination.In undertaking this ninth edition of a venerable classic, my goal is once againto preserve the unique strengths of previous editions, while adding recent information and references, reducing redundancy and improving clarity. The secondedition is one of the few books I have retained from medical school, 35 years ago.The reason is that DeGowin’s Diagnostic Examination emphasizes the unchangingaspects of clinical medicine—the symptoms and signs of disease as related by thepatient and discovered by physical examination.Pathophysiology links the patient’s story of their illness (the history), the physical signs of disease, and the changes in biologic structure and function revealedby imaging studies and laboratory testing. Patients describe symptoms, we needto hear pathophysiology; we observe signs, we need to see pathophysiology; theradiologist and laboratories report findings, we need to think pathophysiology.Understanding pathophysiology gives us the tools to understand disease as alterations in normal physiology and anatomy and illness as the patient’s experienceof these changes.A discussion of pathophysiology (highlighted in blue) occurs after many subject headings. The discussions are brief and included when they assist understanding the symptom or sign. Readers are encouraged to consult physiologytexts to have a full understanding of normal and abnormal physiology [GuytonAC, Hall JE. Textbook of Medical Physiology. 10th ed. Philadelphia: W.B. Saunders Company: 2000. Lingappa VR, Farey K. Physiological Medicine: A ClinicalApproach to Basic Medical Physiology. New York, NY: McGraw-Hill; 2000]. Inaddition, each chapter discusses common syndromes associated with that bodyregion, to provide you with a sense of the common and uncommon but seriousdisease patterns.DeGowin’s Diagnostic Examination is organized as a useful bedside guide toassist diagnosis. Part I introduces the conceptual framework for the diagnosticprocess in Chapter 1, the essentials of history taking and documentation in Chapter 2, and the screening physical examination in Chapter 3. Part I and Chapter17, which introduces the principles of diagnostic testing, should be read andunderstood by every clinician.Part II, Chapters 4 through 14, forms the body of the book. Two introductorychapters discuss the vital signs (Chapter 4) and major physiologic systems that donot have a primary representation in a single body region (Chapter 5). Chapters6

A. The Diagnostic Examination 3 1. Stories: Listen, Examine, Interpret, Explain 3 2. Finding Clues to the Diagnosis 4 3. Select Hypotheses: Generate a Differential Diagnosis 5 4. Cognitive Tests of the Diagnostic Hypotheses 8 5. Selection of Diagnostic Tests 9 6. Rare Diseases 10 7. Certainty and Diagnosis 10 8. Prognostic Uncertainty 10 9 .

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