Oxford Handbook of Clinical Examination and Practical Skills

773 Pages·2014·23.49 MB·English

by  James Thomas

OXFORD MEDICAL PUBLICATIONS
Oxford Handbook of
Clinical Examination
and Practical Skills
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Oxford Handbook of
Clinical
Examination
and Practical
Skills
2nd edition
Edited by
Dr James Thomas
Consultant Musculoskeletal Radiologist
Nottingham University Hospitals NHS
Trust, Nottingham, UK
and
Dr Tanya Monaghan
Academic Clinical Lecturer in Gastroenterology
NIHR Nottingham Digestive Diseases Centre Biomedical
Research Unit,
Nottingham University Hospitals NHS Trust,
Nottingham, UK
1
1

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The moral rights of the authors have been asserted
First Edition published in 2007
Second Edition published in 204
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ISBN 978–0–9–959397–2
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dosages in this book are correct. Readers must therefore always check the product
information and clinical procedures with the most up-to-date published product
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accept responsibility or legal liability for any errors in the text or for the misuse or
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v
Preface
Since the publication of the first edition of this book, we have been heart-
ened by the many positive comments and emails from readers and have
been very grateful for the suggestions for improvements and modifications.
We have tried to incorporate as many of these as possible.
We have tried hard to update the text to reflect modern practice and to
make changes which, only with the 20–20 vision of hindsight, could we see
were needed.
We have tried to keep an eye on OSCE examinations and the reader
will find new ‘skills stations’ throughout the book to add to the existing
examination frameworks.
Several chapters, including respiratory, paediatrics, skin, and locomotor
have been rewritten from scratch.
We have incorporated new chapters on the eyes, the obstetric
assessment.
The ‘important presentations’ section of each systems chapter has been
greatly expanded and referenced to our sister publications the Oxford
Handbooks Clinical Tutor Study Cards.
The practical procedures chapter has been significantly expanded and
updated.
The photographs throughout the book have been updated to reflect
modern healthcare dress codes.
There is a brand new chapter on ‘other investigations’ so that the reader
can understand what is involved in common tests and how to prepare
patients for them.
Finally, the chapter order has been changed to highlight the importa nce of
the ‘core’ system examinations of the cardiovascular, respiratory, abdomi-
nal, and nervous systems.
As always, we welcome any comments and suggestions for improvement
from our reader—this book, after all, is for you.
James D Thomas
Tanya M Monaghan
203
vi
Acknowledgements
We would like to record our thanks to the very many people who have
given their advice and support since the publication of the first edition.
For contributing specialist portions of the book, we thank Dr Caroline
Bodey (Paediatrics), Dr Stuart Cohen (Skin, hair, and nails), Dr John Blakey
(Respiratory), Dr A Abhishek (Locomotor) and Mr Venki Sundaram and Mr
Farid Afshar (Eyes).
Once again, the elderly pages have been penned by the peerless Dr
Richard Fuller who remains a steadfast supporter and is much appreciated.
This edition builds on the work of contributors to the first edition whose
efforts deserve to be recorded again. Thanks then to Heid Ridsdale, Franco
Guarasci, Jeremy Robson, Lyn Dean, Jonathan Bodansky, Mandy Garforth,
and Mike Gaell.
For this edition, Michelle Jie, Muhammad Umer, and Dr Sandeep Tiwari
kindly posed for new and updated photographs. Their bravery made the
process easy and enjoyable. Our continued gratitude goes to our original
models, Adam Swallow, Geoffrey McConnell, and our anonymous female
model. We thank the staff at the Nottingham University Hospitals Medical
Photography Department, in particular Nina Chambers for taking the
photographs.
Additional diagrams for this edition, including the skin pictures, have
been drawn by Dr Ravi Kothari and we thank him for his speedy and
high-quality work.
As well as contributing some material for the procedures chapter, Dr
Yutaro Higashi has remained a grounding force during this process. His wis-
dom and sagely advice throughout have been much appreciated.
Finally, we would like to thank the staff at Oxford University Press for
originally trusting us with this project, especially Catherine Barnes and
Elizabeth Reeves for their faith, support, and guidance.
vii
Contents
How to use this book ix
Contributors x
Symbols and abbreviations xi
 Communication skills 
2 The history 2
3 General and endocrine examination 4
4 Skin, hair, and nails 75
5 The cardiovascular system 99
6 The respiratory system 39
7 The abdomen 67
8 The nervous system 24
9 The eyes 307
0 The locomotor system 349
 The ear, nose, and throat 399
2 The male reproductive system 42
3 The female reproductive system 437
4 The obstetric assessment 463
5 The breast 48
6 The psychiatric assessment 497
viii COnTEnTS
7 The paediatric assessment 525
8 Practical procedures 557
9 Clinical data interpretation 663
20 Other investigations 705
Index 735
ix
How to use this book
The systems chapters
In each chapter, there are suggestions as to what questions to ask and how to
proceed depending on the presenting complaint. These are not exhausti ve and
are intended as guidance. The history parts of each chapter should be used in
conjunction with C hapter 2 to build a full and thorough history.
Practical procedures
This chapter describes those practical procedures that the junior doctor or
senior nurse may be expected to perform. Some should only be performed
once you have been trained specifically in the correct technique by a more
senior colleague.
Reality versus theory
In describing the practical procedures, we have tried to be ‘realistic’. The
methods described are the most commonly used across the profession and
are aimed at helping the reader perform the procedure correctly and safely
within a clinical environment.
There may be slight differences, therefore, between the way that a small
number of the procedures are described here and the way that they are
taught in a clinical skills laboratory. In addition, local trusts may use different
equipment for some procedures. The good practitioner should be flexible
and make changes to their routine accordingly.
Data interpretation
A minority of the reference ranges described for some of the biochemical
tests in the data interpretation chapter may differ very slightly from those
used by your local laboratory—this is dependent on the equipment and
techniques used for measurement. Any differences are likely to be very
small indeed. If in doubt, check with your local trust.