Hutchison's Clinical Methods

529 Pages·1984·25.984 MB·English

by  Michael Swash & Stuart Mason

Published by Bailliere Tindall
1 St Anne's Road, Eastbourne BN21 3UN
© 1984 Bailliere Tindall
All rights reserved. No pan of this publication may be
reproduced, stored in a retrieval system or transmitted, in any
form or by any means, electronic, mechanical, photocopying or
otherwise, without the prior permission of Bailliere Tindall,
1 St Anne's Road, Eastbourne BN21 3UN.
First published 1897
Seventeenth edition 1980
Eighteenth edition 1984
ELBS edition first published 1975
Reprinted 1975, 1976
ELBS edition of the seventeenth edition 1980
Reprinted 1981 (twice), 1982
ELBS edition of the eighteenth edition 1984
Typeset by Inforum Ltd, Portsmouth
Printed in Great Britain by Bemrose Printing - C.I.P., Derby
British Library Cataloguing in Publication Data
Hutchison, Sir Robert, ban
Hutchison's clinical mediods.-—18th ed.
1. Diagnosis
I. Title II. Swash, Michael
III. Mason, Stuart, 1919-
616.07'5 RC71
UK ediuon ISBN 0 7020 1031 6
ELBS edition ISBN 0 7020 1040 5
Hutchison's
Clinical Methods
Eighteenth Edition
Michael Swash MD, FRCP, MRCPath
Consultant Physician to The London Hospital
Stuart Mason MD, FRCP
Hon. Consulting Physician, The London Hospital
ELBS
The English Language Book Society
and
Bailliere Tindall
Preface
This eighteenth edition is the fruit of much revision and some addition.
Nevertheless the book continues the aims set out by Robert Hutchison, who
prefaced the first edition in 1897 with these lines: 'The title Clinical Methods
describes the scope of this book better than any other. It is not intended as a
treatise upon medical diagnosis ... It aims rather at describing those methods
of clinical investigation by the proper application of which a correct diagnosis
can alone be arrived at. To every student when he first begins work in a medical
ward the question presents itself: How shall I investigate this case? To that
question the present work is intended to provide an answer.'
We have emphasized the importance of considering the patient as a person,
not a case, and to that end we have added a chapter on psychiatric assessment.
The chapters on the cardiovascular system and the ear, nose and throat are new
presentations. In them, as in other chapters, we have briefly introduced
modern imaging techniques and physiological tests in order to show how these
illustrate the nature of symptoms and physical signs. There is additional
material in several of the other chapters.
We sadly record the death of Richard Bomford prior to the preparation of
this edition. He was truly a patient's physician and his influence on this book is
abiding.
Once again we are greatly indebted to our colleagues, listed overleaf, for
their contributions. We also pay tribute to our publishers for their skill and
forbearance. The responsibility for any errors is ours alone.
Michael Swash
Stuart Mason
Acknowledgements
We wish to thank the following for their help:
J. M. Pfeffer MB BS, BSc, MRCPsych The psychiatric assessment
H. Baker MD, FRCP The skin
A. D. W. Maclean MB BS, FRCS The abdomen
F. P. Marsh MB BChir, FRCS The urine, The faeces
D. T. D. Hughes BM BCh, FRCP The respiratory system
P. G. Mills BM BCh, MRCP The cardiovascular system
A. W. Morrison MB ChB, FRCS, DLO with The ear, nose and throat
G. S. Kenyon MB ChB, FRCS Ed
The eye
I. S. Levy BM BCh, FRCS
J. D. Perry MB BS, MRCP The locomotor system
G. C. Jenkins MB BS, PhD, FRCPath with The blood
B. T. Colvin MB BChir, MRCP, MRCPath
A. D. M. Jackson MD, FRCP, DCH Examination of children
Contents
List of plates VI
Preface vii
Acknowledgements viii
1 Doctor and patient 1
2 General considerations 25
3 The psychiatric assessment 38
4 The skin, the nails and the hair 64
5 The abdomen 75
6 The urine 133
7 The faeces 163
8 The respiratory system 172
9 The cardiovascular system 198
10 The nervous system 264
11 The unconscious patient 355
12 The ear, nose and throat 365
13 The eye 391
14 The locomotor system 406
15 The blood 429
16 Examination of children 456
17 Using the laboratory 474
Appendix 478
Index 481
List of plates
Between pages 248 and 249
I Intestinal parasites VIII Normal peripheral blood
Normal bone marrow aspirate
II Normal fundus
Primary optic atrophy IX Iron deficiency anaemia
Papilloedema Macrocytic anaemia
III Pseudopapilloedema X Megaloblastic bone marrow
Central retinal vein occlusion Glandular fever
Retinal emboli XI Sickle haemoglobin disease
IV Hypertensive retinopathy 0-Thalassaemia major
Diabetic retinopathy
XII Spherocytosis
Xanthelasmata palpebrarum
Myelomatosis
and cataract
Thyroid eye disease XIII Chronic lymphocytic leukaemia
Chronic granulocytic (myeloid)
V Impetigo
leukaemia
Erysipelas
XIV Smear from uterine cervix
VI Basal cell carcinoma
Sputum cytology
Herpes zoster
XV Ascites cytology
VII Bacterial endocarditis
Cerebrospinal fluid cytology
Purpura in Henoch-Schonlein
disease XVI Parasites of the blood
It is easy to talk of the principles of medicine but difficult to provide accurate
succinct definitions. One statement that gets near to the truth is that 'diagnosis
should precede treatment whenever possible'. There are two steps in making a
diagnosis. The first is observation by history taking, physical examination and
ancillary investigations. The second is interpretation of the information
obtained in terms of a disorder of function and structure, then in terms of
pathology. This book is about observation rather than interpretation; patho
logy, the study of disease, is largely outside its scope. However, information
and interpretation go hand in hand. The nature of further observation is
determined by interpretation of information already obtained. In practice, of
course, patients do not present with a diagnosis; they come with problems.
The wise doctor does not think of himself as a diagnostician but rather as
someone who elucidates human problems. He also realizes that labelling a
disease process is but one step in the management of a problem.
THE HISTORY
The aim is to get from the person concerned an accurate account of his
complaint and to see this against the background of his life as a whole. The
findings should be recorded under the following headings:
1 Presenting complaint
2 History of present illness
3 Previous history of illness
4 Menstrual history
5 Treatment history
2 Doctor and patient
6 Family history
7 Social and occupational history
Some doctors prefer to record the patient's social and occupational history and
the past and family histories before the history of the presenting complaint,
since the patient's presenting illness is then viewed more clearly in the context
of what has happened before. Further, it is often wise to find out about the
patient's life, at least to some degree, before tackling the presenting illness
itself. However, in taking the history it is neither possible nor desirable to tie
a patient down to any particular sequence. He must be allowed to tell his story
in his own way. Further, a good doctor begins the examination of a patient as
the latter walks into the room—his general appearance, the way he walks, the
way he answers questions and so on—and only finishes taking the history when
the consultation is over. Occasionally a vital piece of information may come out
just when the patient is leaving.
The list of headings may appear formidable and it does take some experi
ence to know in a given case which part of the history is particularly worth
pursuing. If, for instance, the patient's complaint is undue bleeding, a careful
family history may virtually make the diagnosis. If he has chest symptoms, the
fact that he worked with asbestos even twenty years earlier {occupational
history) may be the vital clue. If his complaints are those of a severe anaemia, the
fact that he has been treated with chloramphenicol {treatment history) may be
all-important. If he has a fever, the fact that his plane put down in West Africa
{social history) may be the clue. These are rare examples; more commonly it
may be his social circumstances—his relations with his wife or his employer—
that are at fault. When students start case taking they are wise to make at least
some enquiry under all the headings listed. When they have had more experi
ence, they may know on which they should concentrate; but in a difficult case
even the most experienced doctor would be unwise to neglect any of the
headings listed.
In a simple case—provided one can be sure that the case in point is
simple—a few direct questions may obtain all the necessary information. As a
rule it is best just to let the patient talk, even if the process seems time-
consuming. One should 'listen to the patient telling one the diagnosis': the
woman complaining of an itching skin rash may end her story with a remark
that her husband irritates her.
History taking is a special form of the art of communication. It is necessarily a
two-way business: two people studying each other. This is the beginning of the
doctor-patient relationship on which will depend the value of the patient's
history and his confidence in his doctor. For many patients consulting a doctor
is an ordeal as bad as a viva voce for some students. However anxious the
patient is to seek medical advice, he may feel, at the margins of consciousness,
that the doctor is a threatening formidable figure. It is the doctor's job to put
the patient at ease and encourage him to talk freely. To do this you need the
The history 3
right words emphasized by body language or non-verbal communication.
Make it clear from your stance, gestures and expression that the patient has
your whole attention and that you will not be shocked or angered by anything
he says. Gazing out of the window or continually writing notes will put off the
patient.
Common courtesy goes a long way towards good communication. So greet
the patient, by name if possible. Whenever visiting a patient for the first time,
tell him who you are and why you have come to see him. It is usually possible to
start the interview with some non-committal remarks. The discovery of a
common county of origin or a mutual interest in a hobby or a pet may work
wonders. When the patient is telling his story always watch his body language
to see if it matches his words. His eyes may give more information than
his words. The clenched fist may betray tension when the words sound
emotionless.
Never underestimate the power of communication inherent in touching
your patient. Try holding the hand of a frightened old lady and see how it gives
her more comfort than your words of reassurance. When it comes to physical
examination does the patient feel your touch as an attack or caress? Gentleness
is all important; indeed abdominal palpation, to be successful, must be like a
caress. Patients are often greatly reassured by a thorough gentle examination.
It is all part of gaining the patient's confidence.
In telling the history the patient may appear to be evasive; this is seldom, if
ever, deliberate. It may be due to dementia, aphasia or sub-normal intelli
gence, but is commonly due to anxiety or even fright. Sometimes the symp
toms cannot easily be put into words. 'I feel rotten' or 'I just don't feel myself
may be the presenting complaint of a whole spectrum of disorders. Psycho
logical symptoms are often very difficult for the patient to express. Many
, people feel that such symptoms are not respectable ones to present to a doctor
and substitute these symptoms by complaints of vaguely described physical
discomfort, often implying polysymptomatic complaints. Later such a patient
may be able to say that everything is flat and hopeless and there is nothing to
live for; in other words he is depressed. An anxious patient may come with
symptoms of indigestion, headache or palpitations; later he may be able to
voice his ever-present feeling that something awful is about to happen. Indeed
this feeling may have become so much a part of him that he is almost unaware
of it.
Evasiveness is, of course, particularly common if the real problem is a
sexual one or involves feelings of guilt. The spinster caring for a difficult
elderly mother will not easily associate her headaches with her feelings of
anger. It is important for the doctor to recognize the reasons that make a
patient difficult to handle. Anger and exasperation are natural reactions if
there is no determined attempt to tolerate the patient and discover why the
interview is arousing mutual antipathy. We all have our own strengths and
weaknesses in personal relationships. It is the doctor's job to know himself and