Macleod’s Clinical Diagnosis

327 Pages·2018·9.29 MB·English

by  Alan Japp

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Meacleod’s
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Clinical
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Diagnosis
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Macleod’s
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2nd Edition DCe
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Alan G Japp
MBChB(Hons) BSc(Hons) MRCP PhD il
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Consultant Cardioloogist, ao i
Royal Infirmary ofc Edinburgh;
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Honorary Cliniecal Senior Lecturer,
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University of Edinburgh g
UK s is
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Coolin Robertson o o
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BA(Hons) MBChB FRCPGlas FRCSEd
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FICP(Hon) FSAScot e e
Honorary Professor of Accident amnd Emergency a
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Medicine and Surgery,
University of Edinburgh
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UK s
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Co-authors
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Rohana J eWright
MBChB MfDr FRCPEd s
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Consultant Physician,
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St Joohn’s Hospital, o
Loivingston, and Edinburgh Centre for Endocrinology
and Diabetes,
Edinburgh, UK
Matthew J Reed
MA(Cantab) MB BChir MRCS FCEM MD
Consultant and NRS Career Researcher Clinician in
Emergency Medicine,
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Royal Infirmary of Edinburgh;
Honorary Readeer,.
University of Ednburgh
UK
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Andkrew Robson
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MA (Cantab) BM BCh FRCS PhD
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Specialist Registrar in General Surgery,
Royal Infirmary of Edinburgh,
UK
Edinburgh London New York Oxford Philadelphia St Louis Sydney 2018
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© 2018 Elsevrie Ltd. All rights reserved. r
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This book and the individual contributions contained in it are protected under copyright
by the publisher (other than as may be noted herein).
First edition 2013
Second edition 2018
ISBN 9780702069611c
International ISBN 9780702069628
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Notices
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Practitionerfs and researchers must always rely on their own expferience and knowledge
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in evaluating and using any information, methods, compounds or experiments described
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herein. Because of rapid advances in the medical sciences, in particular, independent
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verification of diagnoses and drug dosages should be made To the fullest extent of the
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law, no responsibility is assumed by Elsevier, authors, editors or contributors for any
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injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or
ideas contained in the material herein.
The
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publishers
epolcy is to use
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from sustainable forests
Content Strategist: Laurence Hunter
Content Development Specialist: Helen Leng
Project Manager: Louisa Talbott
Designer: Miles Hitchen
Illustration Manager: Karen Giacomucci
Illustrator: Antbits
Printed in Poland o
Last digit is the print number 9 8 7 6 5 4 3 2 1
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Contents
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Preface vii
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Acknowledgements viii
Abbreviations ix
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SECTIOfN 1 PRINCIPLES OF CLINICAL ASSfESSMENT 1
1. What’s in a diagnosis? 3
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2. Assessing patients: a practical guide 7
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3. The diagnostic process 17
SECTION 2 ASSESSMENT OF COMMON PRESENTING PROBLEMS 22
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4. Abdominal pain 24
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5. Breast lump 46
6. Chest pain 50
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7. Coma and altered consciousness 72
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8. Confusion: delirium and dementia 78
9. Diarrhoea 90
10. Dizziness 96
11. Dysphagia 108
12. Dyspmnoea 112
13. Fatigue 130
14. Fever e 138
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15. Gastrointestinal haemorrhage: haematemesis and rectal bleeding 150
16. Haematuria 158
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17. Haemoptysis 162
18. Headache 166
19. Jaundice 174
vi • CONTENTS
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20. Joint swelling 184
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21. Leg swelling 190
22. Limb weakness 196
23. Low back pain 208
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24. Mobility problems: falls and immobility 214
25. Nausea and vomiting 222
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26. Palpitation 232
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27. Rash: acute generalized skin eruption 240
28 Red eye 250
29. Scrotal swelling 258
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30. Shock 264
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31. Transient loss of consciousness: syncope and seizures 270
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32. Urinary incontinence 282
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33. Vaginal bleeding 288
34. Weight loss 294
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Appendix 301
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Index 305
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Preface
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‘Ninety per cent of diagnoses are made from examination have been marginalized by novel
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the history.’ imaging techniques and disease biomarkers.
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‘Clinical examination is the cornerstone of Neverthele.ss, a focused clinical examination is
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assessment.’ critical to recognizing the sick patient, raising
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r red rflags identifying unsuspected problems and,
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These, sor similar platitudes, will be familiar to isn some cases, revealing signs that cannot sbe
most students in clinical training. Many, however, identified with tests (for example, the mental
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notice a ‘disconnect’ between the importance state examination).
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ascribed to basic clinical skills during teaching Our aim is to show you how to use your core
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and the apparent reliance on sophisticateed inves- clinical skills to maximum advanetage. We offer
tigations in the parallel world of clinicaml practice. a grounded and realistic apmproach to clinical
Modern diagnostics have radically altered the diagnosis with no bias towards any particular
face of medical practice; clinical training is still element of the assessment. Where appropriate,
catching up. We recognize that teachers and we acknowledge the limitations of the history
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textbooks frequently fall into the trap of eulogizing and examination and direct you to the necessary
clinical assessment raother than explaining its investigation. Woe also highlight those instances
actual role in contecmporary diagnosis. where diagncosis is critically dependent on basic
Yet we come teo praise the clinical assessment, clinical aessessment, thereby demonstrating its
not to bury iet The history may not, by itself, vital aend enduring importance. We wish you
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deliver thfe diagnosis in 90% of cases but it evfery success in your training and practice, anfd
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is essential in all cases to generate a logical hope that this book provides at least some small
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diffeorential diagnosis and to guide rationaol measure of assistance. o
inovestigation and treatment. In many ‘developeod’ oAlan Japp
countries, some so-called classical phbysica Colibn Robertson
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signs are rare and certain aspects of the clinical Edinburgh, 2018
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Acknowledgements
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On behalf of the editors and authors, I would Edinburgh (Chapter 28, Red eye); Dr Lydia Ash,
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like to thank Laurence Hunter for encouraging Specialty Registrar, Obstetrics & Gynaecology,
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and facilitating thi.s new edition; and Helen Leng Edinburgh. (Chapter 33, Vaginal bleeding), Mr
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for once again providing the perfect blend of Andrew Duckworth, Specialty Registrar, Ortho-
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tolerance, srupport and discipline. We also thank paerdic Surgery, Edinburgh (Chapter 20, Joint
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everyonse who volunteered suggestions and sswelling) and Mr Neil Maitra, Locum Consultasnt
ideas kfor the 2nd edition, particularly Dr Vicky Urologist, Lanarkshire (Chapter 16, Haemakturia)
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Tallenire, Dr Michael MacMahon and Dr Dean and everyone else who has volunteered ideas,
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Kerslake. Finally we gratefully acknowledge a comments, assistance or a friendly ear.
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valuable contribution to individual chapteers from AJ
Dr Mark Wright, Consultant Ophthalmologist,
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Abbreviations
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Abbreviations that do not appear in this list are spelled out in the main text.
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ABCDE airway, breathing, circulation, DMARD disease-modifying anti-rheumatic
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disabil.ity exposure .drug
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ABG arterial blood gas ECG electrocardiogram/
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ACE rangiotensin-converting enzyme r electrocardiography
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ACPA anti-citrullinated protein antibody EEG electroencephalogram/
ACTH adrenocorticotrophic hormone electroencephalography
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AIDS acquired immunodeficiency ENA extractable nuclear antigen
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syndrome ENT ear, nose and throat
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ALP alkaline phosphatase ERCP endoscopic retrogradee
ALT alanine aminotransferase cholangiopancreatmography
ANA antinuclear antibody ESR erythrocyte sedimentation rate
ANCA antineutrophil cytoplasmic antibody FBC full blood count
APTT activated partial thromboplastin FiO fraction of inspired oxygen
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time GCS Glasgow Coma Scale (score)
ASMA anti-smootho muscle antibody GFR glomoerular filtration rate
ASO anti-strepctolysin O GGT gcamma-glutamyl transferase
AST asparetate aminotransferase GI gastrointestinal
AXR abedominal X-ray GP general practitioner
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BMI fbody mass index GfU genitourinary
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BP blood pressure Hb haemoglobin
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bpm beats per minute hCG human chorionic gonadotropohin
BoS breath sound HIV human immunodeficiency virus
CBG capillary blood glucose HR heart rate
CLO campylobacter-like organism ICP intracranial pressure
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CK creatine kinase ICU intensive care unit
CKD chronic kidney disease ID infectious disease
CNS central nervous system IM intramuscular(ly)
COPD chronic obstructive pulmonary INR internatimonal normalized ratio
disease IV intravenous(ly)
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CPET cardiopuclmonary exercise test IVU inctravenous urogram/urography
CRP C-reac.tive protein JVP .jugular venous pulse
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CRT caepillary refill time LDH lactate dehydrogenase
CSF rcerebrospinal fluid LFT liver function test
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CSU catheter specimen of urine LsIF left iliac fossa
CT computed tomogram/tomography LKM liver kidney microsomal
CTPA computed tomographic pulmonary (antibodies)
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angiography LLQ left lower quadrant
CVP central venous pressure LP lumbar puncture
CXR chest X-ray LUQ left upper quadranmt
DC direct current MRA magnetic resonance angiography