Macleod's Clinical Diagnosis

291 Pages·2013·12.66 MB·English

Macleod’s
Clinical
Diagnosis

For Elsevier
Commissioning Editor: Laurence Hunter
Development Editor: Helen Leng
Project Manager: Caroline Jones
Designer/Design Direction: Miles Hitchen
Illustration Manager: Jennifer Rose
Illustrator: Antbits

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto

Clinical

Diagnosis

Macleod’s

Edited by

Alan G Japp MBChB(Hons) BSc(Hons) MRCP
Cardiology Registrar
Royal Infirmary of Edinburgh
Edinburgh, UK

Colin Robertson BA(Hons) MBChB FRCPEd FRCSEd FSAScot
Honorary Professor of Accident and Emergency Medicine
University of Edinburgh
Edinburgh, UK

Associate Editor
Iain Hennessey MBChB(Hons) BSc(Hons) MRCS
Speciality Trainee in Paediatric Surgery
Alder Hey Children’s Hospital
Liverpool, UK

© 2013 Elsevier Ltd. All rights reserved.

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First published 2013

ISBN 9780702035432
International ISBN 9780702035449
eBook ISBN 9780702051227

British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library

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A catalog record for this book is available from the Library of Congress

Notices
Knowledge and best practice in this field are constantly changing. As new
research and experience broaden our understanding, changes in research
methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they
should be mindful of their own safety and the safety of others, including parties
for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are
advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to
verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners,
relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the publisher nor the authors,
contributors, or editors, assume any liability for any injury and/or damage to
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have been marginalised by the emergence
of novel imaging techniques and disease
biomarkers. However, a focused clinical
examination is critical to recognising the
sick patient, raising red flags, identifying
unsuspected problems and, in some cases,
revealing signs that cannot be identified
with tests (for example, the mental state
examination).
Our aim is to show you how to use your
core clinical skills to maximum advantage.
We offer a grounded and realistic approach
to clinical diagnosis with no bias towards
any particular element of the assessment.
Where appropriate, we acknowledge the
limitations of the history and examination
and direct you to the necessary investi­
gation. However, we also highlight those
instances where diagnosis is critically
dependent on basic clinical assessment,
thereby demonstrating its vital and endur­
ing importance. We wish you every success
in your training and practice, and hope that
this book provides at least some small
measure of assistance.
AJ
CR

‘Ninety per cent of diagnoses are made from the
history.’
‘Clinical examination is the cornerstone of
assessment.’

These, or similar platitudes, will be familiar
to most students in clinical training. Many,
however, will have noticed a glaring ‘dis­
connect’ between the importance ascribed
to basic clinical skills during teaching and
the apparent reliance on sophisticated
investigations in the parallel world of clini­
cal practice. Modern diagnostics have radi­
cally altered the face of medical practice;
clinical training is still catching up. We
recognise that both teachers and textbooks
frequently fall into the trap of eulogising the
clinical assessment rather than explaining
its actual role in contemporary diagnosis.
Yet we come to praise the clinical assess­
ment not to bury it. The history may not, by
itself, deliver the diagnosis in 90% of cases
but it is essential in all cases to generate a
logical differential diagnosis and to guide
rational investigation and treatment. Some
physical signs are now vanishingly rare and
certain aspects of the clinical examination

Preface

v

On behalf of the editors and authors, I
would like to thank Laurence Hunter for his
trust and support; Helen Leng for her
careful scrutiny and remarkable tolerance;
Caroline Jones and Wendy Lee for their
hard work and support; and everyone else
who has volunteered ideas, comments,
assistance or a friendly ear.

On a more personal note, I would like
to acknowledge the teaching of Mike Ford
as a major inspiration for this book and
to thank Deepa Japp for her encourage-
ment, optimism and extraordinary patience
throughout the long months of writing and
editing.
AJ

Acknowledgements

vi

Figs 6.10, 6.12, 25.1: Hampton JR. 150 ECG
Problems, 3rd edn. Edinburgh: Churchill
Livingstone, 2008.

Figs 10.1, 12.3, 17.3, 25.6, 29.1, 29.4:
Boon NA, Colledge NR, Walker BR.
Davidson’s Principles & Practice of Medicine,
20th edn. Edinburgh: Churchill Livingstone,
2006.

Figs 12.1, 12.8, 17.2, 17.4: Corne J,
Pointon K. Chest X-ray Made Easy,
3rd edn. Edinburgh: Churchill Livingstone,
2010.

Figs 26.1, 26.2, 26.4, 26.6, 26.7, 26.11, 26.12,
26.13, 26.14, 26.15, 26.17: Gawkrodger DJ.
Dermatology ICT, 4th edn. Edinburgh:
Churchill Livingstone, 2008.

Fig. 26.3: Kumar P, Clark M. Kumar and
Clark Clinical Medicine, 7th edn. Edinburgh:
Churchill Livingstone, 2009.

Figs 26.5, 26.8, 26.9, 26.10: Bolognia J,
Jorizzo J, Rapini R. Dermatology, 1st edn.
London: Mosby, 2003.

Figs 1.1, 2.1A&B, 4.2, 4.3, 6.1, 12.4, 12.5, 12.6,
17.1, 18.1, 22.2, 27.2, 29.2: Douglas G,
Nicol F, Robertson C. Macleod’s Clinical
Examination,
12th
edn.
Edinburgh:
Churchill Livingstone, 2009.

Figs 2.2A–C, 4.1, 5.1, 11.1, 12.2, 19.1, 22.1,
23.1, 23.2, 23.3, 23.4: Ford MJ, Hennessey I,
Japp A. Introduction to Clinical Examination,
8th edn. Edinburgh: Churchill Livingstone,
2005.

Fig. 4.5A&B: Begg JD. Abdominal X-rays
Made Easy, 2nd edn. Edinburgh: Churchill
Livingstone, 2006.

Figs 6.2, 6.7, 6.11, 25.3, 25.4, 25.5, 29.3, 29.5:
Hampton JR. The ECG in Practice, 5th edn.
Edinburgh: Churchill Livingstone, 2008.

Fig. 6.3: Grubb NR, Newby DE. Churchill’s
Pocketbooks
Cardiology,
2nd
edn.
Edinburgh: Churchill Livingstone, 2006.

Figs 6.6, 6.8, 25.2: Hampton JR. The ECG
Made Easy, 7th edn. Edinburgh: Churchill
Livingstone, 2008.

Figure sources

Colin Mitchell

MBChB MRCP
Consultant Geriatrician, St Mary’s
Hospital, London, UK

Jonathan C L Rodrigues

BSc(Hons) MBChB(Hons) MRCP(UK)
Specialist Registrar in Clinical Radiology,
Severn School of Radiology, Bristol, UK

Lynn M Urquhart

MBChB, MRCP, DTMH
Specialty Registrar in Infectious Diseases
and Clinical Research Fellow Medical
Education, Ninewells Hospital and
Medical School, Dundee, UK

Hugh B Waterson

MRCSEd
Specialist Registrar Trainee in
Orthopaedics, Royal Infirmary of
Edinburgh, Edinburgh, UK

R Benjamin Aldridge

MBChB MSc MRCP MRCS
Clinical Research Fellow in Dermatology,
University of Edinburgh; Specialty
Registrar in Plastic and Reconstructive
Surgery, Canniesburn Unit, Glasgow
Royal Infirmary, UK

Roland C Aldridge

MSc MRCS MRCP
Clinical Lecturer, University of Edinburgh;
Honorary Specialty Registrar in General
Surgery, South East Scotland, Edinburgh,
UK

J Kenneth Baillie

BSc(Hons) MRCP FRCA
Clinical Lecturer, Department of Critical
Care Medicine, University of Edinburgh,
Edinburgh, UK

Xavier L Griffin

MA MSc MRCS
Specialist Registrar in Trauma and
Orthopaedic Surgery, Warwick Medical
School, University of Warwick, Warwick,
UK

Contributors

vii

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Part 1 Principles of clinical assessment

1 What’s in a diagnosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 Assessing patients: a practical guide . . . . . . . . . . . . . . . . . . . . . . . . 7

3 The diagnostic process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Part 2 Assessment of common presenting problems

4 Abdominal pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

5 Breast lump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

6 Chest pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

7 Coma and altered consciousness . . . . . . . . . . . . . . . . . . . . . . . . 70

8 Confusion: delirium and dementia . . . . . . . . . . . . . . . . . . . . . . . . 76

9 Diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

10 Dizziness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

11 Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106

12 Dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110

13 Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128

14 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136

15 Gastrointestinal haemorrhage: haematemesis and rectal bleeding . . . . . . . .148

16 Haematuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156

17 Haemoptysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .160

18 Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164

19 Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .172

20 Joint swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182

21 Leg swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186

22 Limb weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .196

23 Low back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .210

24 Mobility problems: falls and ‘off legs’ . . . . . . . . . . . . . . . . . . . . . .216

25 Palpitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .224

26 Rash: acute generalised skin eruption . . . . . . . . . . . . . . . . . . . . . .232

27 Scrotal swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .242

28 Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .246

29 Transient loss of consciousness: syncope and seizures . . . . . . . . . . . . .252

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

Contents

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi

ix

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xi

Abbreviations

ABG
arterial blood gases
ACE
angiotensin-converting enzyme
ACPA
anti-citrullinated protein antibodies
AIDS
acquired immunodeficiency
syndrome
ALP
alkaline phosphatase
ALT
alanine aminotransferase
ANA
antinuclear antibody
ANCA
antineutrophil cytoplasmic
antibodies
APTT
activated partial thromboplastin time
ASMA
anti-smooth muscle antibodies
ASO
anti-streptolysin O
AST
aspartate aminotransferase
BM
blood glucose meter reading
BMI
body mass index
BP
blood pressure
bpm
beats per minute
BS
breath sounds
CK
creatine kinase
CNS
central nervous system
CPET
cardiopulmonary exercise test
CRP
C-reactive protein
CRT
capillary refill time
CSF
cerebrospinal fluid
CSU
catheter specimen of urine
CT
computed tomogram/tomography
CTPA
computed tomographic pulmonary
angiography
CVP
central venous pressure
CXR
chest X-ray
DC
direct current
DMARDs disease-modifying anti-rheumatic
drugs
ECG
electrocardiogram/
electrocardiography
EEG
electroencephalogram/
electroencephalography
ENA
extractable nuclear antigen
ENT
ear, nose and throat
ERCP
endoscopic retrograde
cholangiopancreatography
ESR
erythrocyte sedimentation rate
FBC
full blood count
GCS
Glasgow Coma Scale (score)
GFR
glomerular filtration rate
GGT
gamma-glutamyl transferase
GI
gastrointestinal

GP
general practitioner
Hb
haemoglobin
HIV
human immunodeficiency virus
HR
heart rate
ICP
intracranial pressure
ID
infectious disease(s)
IM
intramuscular(ly)
INR
International Normalised Ratio
IV
intravenous(ly)
IVU
intravenous urogram/urography
JVP
jugular venous pulse
LDH
lactate dehydrogenase
LFTs
liver function tests
LIF
left iliac fossa
LKM
liver kidney microsomal (antibodies)
LLQ
left lower quadrant
LP
lumbar puncture
LUQ
left upper quadrant
MRA
magnetic resonance angiography
MRCP
magnetic resonance
cholangiopancreatography
MRI
magnetic resonance imaging
MSU
midstream urine (specimen)

NSAID
non-steroidal anti-inflammatory drug
PCR
polymerase chain reaction
PEFR
peak expiratory flow rate
PFTs
pulmonary function tests
PR
per rectum
PRN
pro re nata; whenever required
PSA
prostate-specific antigen
PT
prothrombin time
PV
per vaginam
RF
rheumatoid factor
RIF
right iliac fossa
RLQ
right lower quadrant
RR
respiratory rate
RUQ
right upper quadrant
SC
subcutaneous(ly)
SIRS
systemic inflammatory response
syndrome
SSRI
selective serotonin re-uptake
inhibitor
TFTs
thyroid function tests
TNF
tumour necrosis factor
U+E
urea and electrolytes
UGIE
upper gastrointestinal endoscopy
USS
ultrasound
WBC
white blood count

Abbreviations that do not appear in this list are spelled out in the main text.

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Principles of clinical
assessment

What’s in a diagnosis?...........................................3
Assessing patients: a practical guide....................7
The diagnostic process........................................19

1

PART

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