Clinical Examination: A Systematic Guide to Physical Diagnosis / Edition 6

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More About This Textbook


The sixth edition of Clinical Examination continues to serve all medical trainees with a clear explanation of history taking and clinical examination. Set out systematically, this best-selling textbook has comprehensive coverage of the essential skills necessary for clinically evaluating patients.


StudentConsult - free and complete online access

full colour with superior artwork and design

thoroughly evidence-based

New to this edition

includes coverage of ENT and ophthalmology

expanded history taking sections including new differential diagnosis tables

more anatomy content and illustrations - new 'examination anatomy' sections with drawings and descriptions to assist in examination technique and understanding

expanded evidence-based medicine references - the only physical examination trainees book with detailed references and an evidence-based approach; new section on inter-observer variability and kappa values

vital history questions suggesting urgent or important diagnoses specially marked

'Questions to ask the patient' boxes help with history taking for most important areas

new material on DVD includes OSCEs, ECGs and an imaging library

The authors are particularly grateful to Professor Steven McGee for the use of evidence-based medicine tables and information from his important and highly recommended book, Evidence Based Clinical Examination, 2nd edn. St Louis: Elsevier. 2007

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Product Details

  • ISBN-13: 9780729539050
  • Publisher: Elsevier Health Sciences
  • Publication date: 1/12/2010
  • Edition number: 6
  • Pages: 480
  • Product dimensions: 7.70 (w) x 10.20 (h) x 1.00 (d)

Table of Contents

Foreword v

Preface xi

Acknowledgments xii

Clinical methods: an historical perspective xiv

The Hippocratic oath xvi

Credits xvii

Chapter 1 The general principles of history taking 1

Bedside manner and establishing rapport 1

Obtaining the history 2

Introductory questions 2

The presenting (principal) symptom 3

History of the presenting illness 3

Current symptoms

associated symptoms

current treatment and drug allergies

menstrual history

the effect of the illness

The past history 5

The social and personal history 6



occupation and education

overseas travel and immunization

marital status, social support and living conditions

The family history 8

Systems review 8

Skills in history taking 11

References 11

Chapter 2 Advanced history taking 13

Taking a good history 13

The differential diagnosis 13

Fundamental considerations when taking the history 14

Personal history taking 14

The sexual history

Cross-cultural history taking 16

The 'uncooperative' or 'difficult' patient and the history 16

History taking for the maintenance of good health 17

The elderly patient 18

Activities of daily living (ADL)

mental state

specific problems in the elderly

Evidence-based history taking and differential diagnosis 19

The clinical assessment 19

Concluding the interview 20

References 20

Suggested reading 21

Chapter 3 The general principles of physical examination 23

First impressions 24

Vital signs 24

Facies 25





Weight, body habitus and posture 26

Hydration 27

The hands and nails 28

Temperature 28

Smell 29

Preparing the patient for examination 30

Evidence-based clinical examination 30

Inter-observer agreement (reliability) and the κ-statistic

References 32

Suggested reading 34

Chapter 4 The cardiovascular system 35

The cardiovascular history 35

Presenting symptoms

risk factors for coronary artery disease


past history

social history

Examination anatomy 45

The cardiovascular examination 47

Positioning the patient

general appearance


arterial pulse

blood pressure




the back


lower limbs

peripheral vascular disease

acute arterial occlusion

deep venous thrombosis

varicose veins

Correlation of physical signs and cardiovascular disease 76

Cardiac failure

chest pain

pericardial disease

systemic hypertension

pulmonary hypertension

innocent murmurs

valve diseases of the left heart

valve diseases of the right heart


acyanotic and cyanotic congenital heart disease

'grown-up' congenital heart disease

The chest X-ray: a systematic approach 96

Frontal film

lateral film

examples of chest X-rays in cardiac diseas

Summary 102

The cardiovascular examination: a suggested method

References 104

Suggested reading 105

Chapter 5 The respiratory system 107

The respiratory history 107

Presenting symptoms


past history

occupational history

social history

family history

The respiratory examination 115

Examination anatomy

positioning the patient

general appearance








bedside assessment of lung function

Correlation of physical signs and respiratory disease 128

Consolidation (lobar pneumonia)

atelectasis (collapse)

pleural effusion


tension pneumothorax


bronchial asthma

chronic obstructive pulmonary disease

chronic bronchitis

interstitial lung disease




carcinoma of the lung


pulmonary embolism

The chest X-ray 137

Chest X-ray checklist

Summary 141

The respiratory examination: a suggested method

References 142

Suggested reading 143

Chapter 6 The gastrointestinal system 145

The gastrointestinal history 145

Presenting symptoms


past history

social history

family history

The gastrointestinal examination 153

Examination anatomy

positioning the patient

general appearance




neck and chest



rectal examination



Examination of the gastrointestinal contents 183



Urinalysis 184

Examination of the acute abdomen 185

Correlation of physical signs and gastrointestinal disease 187

Liver disease

portal hypertension

hepatic encephalopathy


assessment of gastrointestinal bleeding


inflammatory bowel disease

The abdominal X-ray: a systematic approach 192


bowel gas pattern

bowel dilatation



Summary 194

The gastrointestinal examination: a suggested method

References 196

Suggested reading 197

Chapter 7 The genitourinary system 199

The genitourinary history 199

Presenting symptoms

menstrual and sexual history


past history

social history

family history

The genitourinary examination 207

General appearance






abdominal examination



blood pressure


The urine 212




specific gravity

chemical analysis



glucose and ketones



the urine sediment

Male genitalia 215

Differential diagnosis of a scrotal mass

Pelvic examination 217

Summary 219

Examination of a patient with chronic kidney disease: a suggested method

References 219

Suggested reading 221

Chapter 8 The haematological system 223

The haematological history 223

Presenting symptoms


past history

social history

family history

The haematological examination 224

Examination anatomy

general appearance



epitrochlear nodes

axillary nodes


cervical and supraclavicular nodes

bone tenderness

the abdominal examination

inguinal nodes



Examination of the peripheral blood film 231

Correlation of physical signs and haematological disease 231



acute leukaemia

chronic leukaemia

myeloproliferative disease


multiple myeloma

Summary 238

The haematological examination: a suggested method

References 240

Suggested reading 240

Chapter 9 The rheumatological system 241

The rheumatological history 241

Presenting symptoms

treatment history

past history

social history

family history

Examination anatomy 246

Joint structures

The rheumatological examination 247

General inspection

principles of joint examination

assessment of individual joints

Correlation of physical signs and rheumatological disease 276

Rheumatoid arthritis

seronegotive spondyloarthropathies

gouty arthritis

calcium pyrophosphate arthropathy (pseudogout)

calcium hydroxyapatite arthropathy

systemic lupus erythematosus

scleroderma (progressive systemic sclerosis)

rheumatic fever

the vasculitides

softtissue rheumatism

nerve entrapment syndromes

References 292

Suggested reading 293

Chapter 10 The endocrine system 295

The endocrine history 295

Presenting symptoms

past history

social history

family history

The endocrine examination 297




calcium metabolism

syndromes associated with short stature



diabetes mellitus

Paget's disease (osteitis deformans)

Summary 322

The endocrine system: a suggested method of examination

References 322

Suggested reading 322

Chapter 11 The nervous system 323

The neurological history 323

Headache and facial pain

faints and fits


visual disturbances and deafness

disturbances of gait

disturbed sensation or weakness in the limbs

tremor and involuntary movements

speech and mental status

past health

medication history

social history

family history

The neurological examination 329

Examination anatomy

general signs

cranial nerves

head and neck

limbs and trunk

upper limbs

lower limbs


speech and higher centres

cerebral hemispheres

Correlation of physical signs and neurological disease 383

Upper and lower motor neurone lesions

motor neurone disease

peripheral neuropathy

Guillain-Barré syndrome (acute inflammatory polyradiculoneuropathy)

multiple sclerosis

thickened peripheral nerves

spinal cord compression

important spinal cord syndromes


dystrophia myotonica

myasthenia gravis

the cerebellum

Parkinson's disease

other extrapyramidal movement disorders (dyskinesia)

The unconscious patient 400

General inspection

level of consciousness


head and face

upper and lower limbs


coma scale

Summary 403

Examining the nervous system: a suggested method

References 406

Suggested reading 407

Chapter 12 The psychiatric history and mental state examination 409

Obtaining the history 409

Introductory questions

history of the presenting illness

past history and treatment history

family history

social and personal history

The mental state examination 416

The diagnosis 416

References 422

Suggested reading 422

Chapter 13 The ears, eyes, nose and throat 423

The eyes 423

Examination anatomy

examination method


Horner's syndrome





The ears 430

Examination anatomy

examination method

The nose 433

Examination method


The throat 433

Examination anatomy

examination method



Reference 434

Chapter 14 The breasts 435

History 435

Examination 435



evaluation of a breast lump

References 437

Chapter 15 The skin, nails, and lumps 439

The dermatological history 439

Examination anatomy 440

General principles of physical examination of the skin 441

How to approach the clinical diagnosis of a lump 442

Correlation of physical signs and skin disease 443


erythrosquamous eruptions

blistering eruptions


pustular and crusted lesions

dermal plaques

erythema nodosum

erythema multiforme


flushing and sweating

skin tumours

The nails 451

Summary 452

The dermatological examination in internal medicine: a suggested method

References 454

Suggested reading 454

Chapter 16 A system for the infectious diseases examination 455

Pyrexia of unknown origin 455



HIV infection and the acquired immunodeficiency syndrome (AIDS) 457


References 459

Suggested reading 460

Appendix I Writing and presenting the history and physical examination 461

Appendix II A suggested method for a rapid screening physical examination 464

Appendix III The pre-anaesthetic medical examination (PAME) 466

Index 468

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