These ashcards will help you to brush up on your diagnostic examination procedural skills by asking questions that test your knowledge and provide answers that impart mustknow information.
Each of the 250 two-sided cards contains an openended question with a concise, bulleted answer on the ip side. This unique review focuses on the diagnoses most frequently tested on the USMLE Step 2 and 3 examinations.
It is not easy to give exact and complete details of an operation in writing; but the reader should form an outline of it from the description.
—h ippocRates “ O n JOints ”
[Studies] perfect nature, and are perfected by experience: for natural abilities are like natural plants, that need pruning, by study; and studies themselves, do give forth directions too much at large, except they be bounded in by experience. Crafty men contemn studies, simple men admire them, and wise men use them; for they teach not their own use; but that is a wisdom without them, and above them, won by observation. Read not to contradict and confute; nor to believe and take for granted; nor to nd talk and discourse; but to weigh and consider.
—FRancis Bacon “ O f s tudies ”
A little observation and much reasoning lead to error; many observations and a little reasoning to truth.
—d R. a Lexis c aRReL
It is only by persistent intelligent study of disease upon a methodical plan of examination that a man gradually learns to correlate his daily lessons with the facts of his previous experience and that of his fellows, and so acquires clinical wisdom.
Eliot quotation from: T.S. Eliot. The Complete Poems and Plays, 1909–1950. New York, Harcourt, Brace & World, Inc., 1971.
Frazer quotation from: Sir James George Frazer. The Golden Bough, A Study in Magic and Religion, abridged edition. New York, MacMillan Publishing Company, 1922.
Hippocrates quotation from: Jacques Jouanna (M.B. DeBevoise translator). Hippocrates. Baltimore, The Johns Hopkins University Press, 1999.
Osler quotation from: Sir William Osler. Aequanimitas, with other Addresses to Medical Students, Nurses and Practictioners of Medicine. Philadelphia, P. Blakiston’s Son and Co., 1928.
Roethke quotations from: Theodore Roethke. On Poetry and Craft. Port Townsend, Washington Copper Canyon Press, 2001.
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R prEFaCE
To The Reader:
Pray thee, take care, that tak’st my book in hand
To read it well: that is, to understand.
—Ben Jonson
The clinician’s goal in performing a history and physical examination is to generate diagnostic hypotheses. This was true for Hippocrates and Osler and remains true today. The purpose of DeGowin’s Diagnostic Examination is to encourage a thoughtful, systematic approach to the history, physical examination, and diagnostic process.
The practice of medicine would be simple if each symptom or sign indicated a single disease. There are enormous numbers of symptoms and signs (we cover several hundred) that can occur in a nearly in nite number of combinations and temporal patterns. These symptoms and signs are the rough bers from which the clinician must weave a clinical narrative, anatomically and pathophysiologically explicit, forming the diagnostic hypotheses. Mastering the diagnostic process requires:
(1) Knowledge: Familiarity with the pathophysiology, symptoms, and signs of common and unusual diseases.
(2) Skill: The ability to take an accurate and complete history and perform an appropriate physical examination.
(3) Experience: From longitudinal exposure to many clinical situations, diseases, and patients, each thoroughly evaluated, the skilled clinician develops familiarity with the presenting symptoms and signs of a wide variety of pathophysiologic processes allowing him to generate a probabilistic differential diagnosis for each new patient.
(4) Judgment: Knowledge of medical science and the medical literature, combined with re ective experience, develops the judgment necessary to ef ciently test the hypotheses in the laboratory or by clinical interventions [Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet. 2003;362:1100–1105].
DeGowin’s Diagnostic Examination has been used by students and clinicians for over 40 years precisely because of its usefulness in this diagnostic process:
(1) It describes the techniques for obtaining a complete history and performance of a thorough physical examination.
(2) It links symptoms and signs with the pathophysiology of disease.
(3) It presents an approach to differential diagnosis, based upon the pathophysiology of disease, which can be ef ciently tested in the laboratory.
(4) 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 history taking and physical examination.
In undertaking this tenth edition of a venerable classic, my goal is once again to preserve the unique strengths of previous editions, while adding recent information and references, reducing redundancy, and improving clarity. The second edition is one of the few books I have retained from medical school, 40 years ago. The reason is that DeGowin’s Diagnostic Examination emphasizes the unchanging aspects of clinical medicine—the symptoms and signs of disease as related by the patient 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 revealed by imaging studies and laboratory testing. Patients describe symptoms, we need to hear pathophysiology; we observe signs, we need to see pathophysiology; the radiologist and laboratories report ndings, we need to think pathophysiology. Pathophysiology and pathologic anatomy provide the framework to understand disease as alterations in normal physiology and anatomy, and illness as the patient’s experience of these changes.
A discussion of pathophysiology (highlighted in the second color) occurs after many subject headings. The discussions are brief and included when they assist understanding the symptom or sign. Readers are encouraged to consult physiology texts to have a full understanding of normal and abnormal physiology [Guyton AC, Hall JE. Guyton and Hall Textbook of Medical Physiology . 12th ed. Philadelphia, PA: W.B. Saunders Company: 2011]. In addition, each chapter discusses syndromes associated with that body region to give a sense of the common, and uncommon but serious, disease patterns.
DeGowin’s Diagnostic Examination is organized as a useful bedside guide to assist diagnosis. Part 1, Chapter 1 introduces the conceptual framework for the diagnostic process, Chapter 2 the essentials of history taking and documentation, and Chapter 3 the screening physical examination with a short introduction to bedside ultrasound. Part 1 and Part 4, Chapter 17, which introduces the principles of diagnostic testing, should be read and understood by every clinician.
Part 2, Chapters 4 through 14, forms the body of the book. Two introductory chapters discuss the vital signs (Chapter 4) and major physiologic systems that do not have a primary representation in a single body region (Chapter 5). Chapters 6 to 14 are organized around the body regions sequentially examined during the physical examination. Each chapter has a common structure outlined in the Introduction and User’s Guide. To avoid duplication, the text is heavily cross-referenced. I hope the reader will nd this useful and not too cumbersome.
References to articles from the medical literature are included in the body of the text. We have chosen articles that provide useful diagnostic information including excellent descriptions of diseases and syndromes, thoughtful discussions of the approach to differential diagnosis and evaluation of common and unusual clinical problems, and, in some cases, photographs illustrating key ndings. Most references are from the major general medical journals, the New England Journal of Medicine, the Lancet, the Annals of Internal Medicine, and the Journal of the American Medical Association. This implies that a clinician who regularly studies these journals will keep abreast of the broad eld of medical diagnosis. Some references are dated in their recommenda-
tions for laboratory testing and treatment; they are included because they give thorough descriptions of the relevant clinical syndromes, often with excellent discussions of the approach to differential diagnosis. Tests and treatments come and go, but good thinking has staying power. The reader must always check current resources before initiating a laboratory evaluation or therapeutic program.
Evidence-based articles on the utility of the physical examination are included, mostly from the Rational Clinical Examination series published over the last 20 years in the Journal of the American Medical Association. They are included with the caveat that they evaluate the physical examination as a hypothesis-testing tool, not as a hypothesis generating task. The emphasis on transforming the qualitative hypothesis generating task of the history and physical examination into a quantitative hypothesis testing task is, I think, misguided [Feinstein AR. Clinical Judgement revisited: the distraction of quantitative models. Ann Intern Med. 1994;120:799–805].
Each chapter was independently reviewed by faculty members of the University of Iowa Roy J. and Lucille A. Carver College of Medicine. Their feedback and assistance is gratefully acknowledged. Reviewers for this edition are Jane Engeldinger, MD, Professor, Clinical Obstetrics and Gynecology (Chapters 10 and 11); Christopher J. Goerdt, MD, MPH, Associate Professor, Clinical Internal Medicine, Division of General Internal Medicine (Chapters 1–4); Vicki Kijewski, MD, Assistant Professor of Clinical Psychiatry and Internal Medicine (Chapter 15); Victoria Jean Allen Sharp, MD, MBA, Clinical Associate Professor, Departments of Urology and Family Medicine (Chapters 10 and 12); William B. Silverman, MD, Professor, Clinical Internal Medicine, Division of Gastroenterology and Hepatobiliary Diseases (Chapter 9); Haraldine A. Stafford, MD, PhD, Associate Professor, Clinical Internal Medicine, Division of Rheumatology (Chapter 13); and Michael Wall, MD, Professor of Neurology and Ophthalmology (Chapters 7 and 14).
My co-authors for this edition, Donald D. Brown, MD, Joseph Szot MD, and Manish Suneja MD, have been instrumental in seeing that the tenth edition maintains the strengths of previous editions while continuing to evolve to meet the reader’s needs. Dr. Brown directed the history taking and physical examination course at the University of Iowa for over 25 years. He is annually nominated for best teacher awards by the students in recognition of his knowledge and enthusiasm for teaching these essential skills. As a practicing cardiologist, he is the primary editor for Chapters 8 and 16. Dr. Szot is a general internist and Dr. Suneja is a general internist with subspecialty certi cation in Nephrology. They are Associate Program Directors in the University of Iowa Internal Medicine Residency Program.
This is the rst time that DeGowin’s Diagnostic Examination does not have direct participation by the DeGowin family of physicians. We, of course, are building on the solid foundation they have built and which we will continue to honor with the book’s title.
Ms. Christine Diedrich and Mr. James Shanahan, our sponsoring editors, and Mr. Robert Pancotti, our project development editor, at McGrawHill, have been actively involved from the beginning in the planning and execution of the tenth edition. Their encouragement and support are deeply appreciated. The McGraw-Hill editorial and publishing staff have been prompt and professional throughout manuscript preparation, editing, and production.
For the tenth edition, a standard e-book edition is available, as is an enhanced e-book edition that includes embedded video segments demonstrating fundamental physical examination procedures. We have included complimentary access to ve of these videos in the standard print and e-book editions. The videos are available at: mhprofessional.com/diagnosticexam/ I wish to thank my colleagues who have encouraged me throughout the course of this project. I have incorporated many suggestions from my coauthors and each of the reviewers; any remaining de ciencies are mine. Ultimately, you, the reader, will determine the strengths and weaknesses of this edition. I welcome your feedback and suggestions. Email your comments to rleblond@billingsclinic.org (please include “DeGowin’s” on the subject line).
Richard F. LeBlond, MD, MACP Billings, Montana
R
COmmON aBBrEVIaTIONs
CHF congestive heart failure
COPD chronic obstructive pulmonary disease
CLL chronic lymphocytic leukemia
CML chronic myelogenous leukemia
CMV cytomegalovirus
CN cranial nerve
CNS central nervous system
CSF cerebrospinal uid
CVP central venous pressure
DDX differential diagnosis
DIP distal interphalangeal joint
EBV Epstein–Barr virus
HIT heparin-induced thrombocytopenia
HSV herpes simplex virus
ITP idiopathic immune thrombocytopenia
LLQ left lower quadrant
LUQ left upper quadrant
LV left ventricle
MCP metacarpal–phalangeal joint
MI myocardial infarction
MS multiple sclerosis
MTP metatarsal–phalangeal joint
NBTE nonbacterial thrombotic endocarditis
PE pulmonary embolism
PIP proximal interphalangeal joint
RA rheumatoid arthritis
RLQ right lower quadrant
RUQ right upper quadrant
RV right ventricle
SBE subacute bacterial endocarditis
SLE systemic lupus erythematosus
TTP thrombotic thrombocytopenic purpura
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R INTrOd CTION aNd sEr’s g IdE
Read with two objectives: rst to acquaint yourself with the current knowledge on the subject and the steps by which it has been reached; and secondly, and more important, read to understand and analyze your cases.
—s iR W iLLiam o sLeR “ The Student Life”
DeGowin’s Diagnostic Examination provides the introductory knowledge base, describes the skills, and encourages the reader to acquire the experience and judgment needed to become a master clinical diagnostician. Despite recent advances in testing and imaging, the clinician’s skills in taking a history and performing a physical examination are needed now more than ever.
The history is the patient’s story of his or her illness related as the time course of their symptoms; the physical examination reveals the signs of disordered anatomy and physiology. The symptoms and signs of disease form temporal patterns, which the clinician recognizes from experience and knowledge of anatomy, physiology, and diseases. From the history and physical examination, the clinician generates testable pathophysiologic and diagnostic hypotheses— the differential diagnosis. Pro ciency and con dence in differential diagnosis should improve with regular use of DeGowin’s Diagnostic Examination .
The differential diagnosis is subjected to laboratory testing. Proper use of the laboratory and imaging are based upon accurate diagnostic hypotheses generated while taking the history and performing the physical examination. Undisciplined use of both laboratory tests and imaging modalities is a major cause of increasing healthcare costs and leads to further inappropriate testing and patient harm [Qaseem A, Alguire P, Feinberg LE, et al. Appropriate use of screening and diagnostic test to foster high-value, cost-conscious care. Ann Intern Med. 2012; 156:147–149]. Over-reliance on technology has contributed to loss of clinical bedside skills.
DeGowin’s Diagnostic Examination is intended to assist the student and clinician in making reasonable diagnostic hypotheses from the history and physical examination. Part 1, Chapters 1 to 3, discuss the diagnostic framework in detail. Chapter 1 discusses the importance of diagnosis and the process of forming a differential diagnosis speci c to each patient. Chapter 2 discusses the process of history taking and documentation of the ndings in the medical record. Chapter 3 outlines the screening physical examination.
The heart of DeGowin’s Diagnostic Examination is Part 2, Chapters 4 to 15. It is organized in the sequence in which the clinician traditionally performs the examination. Chapter 4 discusses the vital signs. Chapter 5 introduces some systems to keep in mind throughout the examination since they present with symptoms and signs not easily referable to a speci c body region. Chapters 6 to 13 discuss the diagnostic examination by body region: the skin (Chapter 6), the head and neck (Chapter 7), the chest and breasts (Chapter 8), the abdomen (Chapter 9), the urinary system (Chapter 10), the female genitalia and reproductive system (Chapter 11), the male genitalia and reproductive system
(Chapter 12), the spine and extremities (Chapter 13), the neurologic examination (Chapter 14), and the psychiatric and social evaluations (Chapter 15).
Parts 3 and 4 provide supplemental information. Chapter 16 discusses the preoperative examination. The intent is to give the reader a framework for evaluating the medical risks in the perioperative period and an approach to communicating those risks to the patient and surgeon. Chapter 17 introduces the principles of laboratory testing and imaging critical to an ef cient use of the laboratory and radiology. Chapter 18 lists many common (not “routine”) laboratory tests that provide important information about the patient’s condition not accessible from the history or physical examination. More specialized tests used to evaluate speci c diagnostic hypotheses are not discussed.
Chapters 6 to 14 have a uniform organization: (A) each chapter begins with a brief overview of the major organ systems to be considered; (B) next is a discussion of the super cial and deep anatomy of the body region; (C) the physical examination of the region or system is described in detail in the usual order of performance; (D) the symptoms particularly relevant to the body region and systems are presented; (E) the physical signs in the region or system examinations are listed (some ndings can be both symptoms and signs; discussion of a nding is in the section where it is most likely to be encountered, then cross-referenced in the other section); and (F) discusses diseases and syndromes commonly in the differential diagnosis of symptoms and signs in the body region and systems under discussion. To avoid duplication, the text is heavily cross-referenced.
Brief discussions of many diseases and clinical syndromes are included so the reader can appreciate the patterns of symptoms and signs they commonly manifest. This will help the clinician determine whether that disease or syndrome should be included in the differential diagnosis of the symptoms and signs in their speci c patient. Particularly useful points of differentiation are listed after the DDX symbol.
DeGowin’s Diagnostic Examination is not a textbook of medicine. The reader must use this with a comprehensive textbook of medicine to fully understand the diseases and syndromes. We strongly recommend Harrison’s Principles of Internal Medicine as a companion text [Hauser SL, Jameson JL, Loscalzo J, et al eds. Harrison’s Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2011].
We emphasize the characteristics of diseases because a clinician who knows the manifestations of many diseases will ask the right questions, obtain the key history, and elicit the pertinent signs that differentiate one disease from another. Instructions on how to elicit the speci c signs are included in the physical examination section for each region; if the maneuver is not part of the usual examination, it is discussed with the sign itself. Following the descriptions of many symptoms and signs is a highlighted CLINICAL OCCURRENCE section. This is a list of diseases often associated with the symptom or sign. The organization of the Clinical Occurrence section is based upon the approach to the differential diagnosis of the symptom or sign felt to be most clinically useful. Where a broad differential exists, we have introduced an organizational scheme for the CLINICAL OCCURRENCE based upon the pathophysiologic mechanisms of disease. The clinician can often narrow their differential diagnosis to one or a few basic mechanisms of disease: congenital, endocrine, idiopathic, infectious, in ammatory/immune, mechanical/traumatic, metabolic/toxic, neoplastic, neurologic, psychosocial, or vascular. This facilitates
the creation of a limited yet reasonable differential diagnosis. The categories in this scheme are not mutually exclusive; a congenital syndrome may be metabolic, infections are usually accompanied by in ammation, and a neoplastic process may cause mechanical obstruction. Although not rigid, this is a useful conceptual construct for thinking about the patient’s problems. Critical symptoms, signs, syndromes, and diseases are noted by the • marginal symbol. These are symptoms, signs, syndromes, and diseases that may indicate an emergent condition requiring immediate and complete evaluation. By using our understanding of normal and abnormal anatomy and physiology as the basis for thinking within clinical medicine, it is possible to avoid the trap of “word space.” This is the term one of us (RFL) has given to the common practice of using lists and word association as an approach to diagnosis: associating a word (for instance, cough) with a memorized list of other words (pneumonia, bronchitis, asthma, postnasal drip, gastroesophageal re ux, etc.). The inherent emphasis on memorization in this scheme is the bane of all medical students; fortunately, it is not only unnecessary, it is counterproductive. Cough is a protective re ex arising from sensory phenomena in the upper airway, bronchi, lungs, and esophagus mediated through peripheral and central nervous system pathways and executed by coordinated contraction of the diaphragm, chest wall, and laryngeal muscles. With this physiologic context, and our understanding of the mechanisms of disease, we can hypothesize the irritants most likely to be relevant in each speci c patient. New diseases are being encountered with surprising frequency. They present not with new symptoms and signs, but with new combinations of the old symptoms and signs. It is our hope that the reader will learn to recognize the patterns of known diseases and to be alert for patterns that are unfamiliar (those not yet in their knowledge base) or previously unrecognized (the new diseases). HIV/AIDS was recognized as an unprecedented clinical syndrome with a new pattern of familiar symptoms (weight loss, fever, fatigue, dyspnea, cough) and signs (wasting, generalized lymphadenopathy, mucocutaneous lesions, Kaposi’s sarcoma, opportunistic infections) in a unique population (homosexual males and IV drug users). Continuous expansion of our personal knowledge of the known while welcoming the unfamiliar and unknown is the excitement of clinical practice.
The proper testing of speci c diagnostic hypotheses is beyond the scope of this book. It is subject to constant change as new tests are developed and their usefulness evaluated in clinical trials. Part 4 discusses the principles of laboratory testing (Chapter 17) and some common laboratory tests (Chapter 18). The reader should consult Harrison’s Principles of Internal Medicine, 18th edition, and the current literature when selecting speci c tests to evaluate their diagnostic hypotheses [Guyatt G, Rennie D, eds. Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Chicago, IL: AMA Press; 2002; Guyatt G, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. New York, NY: McGraw-Hill; 2008].
e ’ gui e:
DeGowin’s Diagnostic Examination can be read cover to cover with bene t to the student or practitioner; however, most will not, and should not, choose this strategy. As Osler said, read to understand your patients and to answer your questions.
