Oxford Handbook of Clinical Examination and Practical Skills

773 Pages·2014·23.485 MB·English

by  James Thomas, Tanya Monaghan

OXFORD MEDICAL PUBLICATIONS
Oxford Handbook of
Clinical Examination
and Practical Skills
Published and forthcoming Oxford Handbooks
Oxford Handbook for the Foundation Oxford Handbook of Genetics
Programme 3e Oxford Handbook of Genitourinary
Oxford Handbook of Acute Medicine, HIV and AIDS 2e
Medicine 3e Oxford Handbook of Geriatric
Oxford Handbook of Anaesthesia 3e Medicine 2e
Oxford Handbook of Applied Dental Oxford Handbook of Infectious
Sciences Diseases and Microbiology
Oxford Handbook of Cardiology 2e Oxford Handbook of Key Clinical
Oxford Handbook of Clinical and Evidence
Laboratory Investigation 3e Oxford Handbook of Medical
Oxford Handbook of Clinical Dermatology
Dentistry 6e Oxford Handbook of Medical Imaging
Oxford Handbook of Clinical Oxford Handbook of Medical
Diagnosis 3e Sciences 2e
Oxford Handbook of Clinical Oxford Handbook of Medical Statistics
Examination and Practical Skills 2e Oxford Handbook of Neonatology
Oxford Handbook of Clinical Oxford Handbook of Nephrology and
Haematology 3e Hypertension 2e
Oxford Handbook of Clinical Oxford Handbook of Neurology 2e
Immunology and Allergy 3e Oxford Handbook of Nutrition and
Oxford Handbook of Clinical Dietetics 2e
Medicine – Mini Edition 8e Oxford Handbook of Obstetrics and
Oxford Handbook of Clinical Gynaecology 3e
Medicine 9e Oxford Handbook of Occupational
Oxford Handbook of Clinical Pathology Health 2e
Oxford Handbook of Clinical Oxford Handbook of Oncology 4e
Pharmacy 2e Oxford Handbook of
Oxford Handbook of Clinical Ophthalmology 3e
Rehabilitation 2e Oxford Handbook of Oral and
Oxford Handbook of Clinical Maxillofacial Surgery
Specialties 9e Oxford Handbook of Orthopaedics
Oxford Handbook of Clinical and Trauma
Surgery 4e Oxford Handbook of Paediatrics 2e
Oxford Handbook of Complementary Oxford Handbook of Pain Management
Medicine Oxford Handbook of Palliative Care 2e
Oxford Handbook of Critical Care 3e Oxford Handbook of Practical Drug
Oxford Handbook of Dental Therapy 2e
Patient Care Oxford Handbook of Pre-Hospital Care
Oxford Handbook of Dialysis 3e Oxford Handbook of Psychiatry 3e
Oxford Handbook of Emergency Oxford Handbook of Public Health
Medicine 4e Practice 3e
Oxford Handbook of Endocrinology Oxford Handbook of Reproductive
and Diabetes 3e Medicine & Family Planning 2e
Oxford Handbook of ENT and Head Oxford Handbook of Respiratory
and Neck Surgery 2e Medicine 3e
Oxford Handbook of Epidemiology for Oxford Handbook of Rheumatology 3e
Clinicians Oxford Handbook of Sport and
Oxford Handbook of Expedition and Exercise Medicine 2e
Wilderness Medicine Handbook of Surgical Consent
Oxford Handbook of Forensic Medicine Oxford Handbook of Tropical
Oxford Handbook of Gastroenterology Medicine 4e
& Hepatology 2e Oxford Handbook of Urology 3e
Oxford Handbook of General
Practice 4e
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

Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 204
The moral rights of the authors have been asserted
First Edition published in 2007
Second Edition published in 204
Impression: 
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
98 Madison Avenue, New York, NY 006, United States of America
British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number: 204933
ISBN 978–0–9–959397–2
Printed in China by
C&C Offset Printing Co. Ltd
Oxford University Press makes no representation, express or implied, that the drug
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
information and data sheets provided by the manufacturers and the most recent
codes of conduct and safety regulations. The authors and the publishers do not
accept responsibility or legal liability for any errors in the text or for the misuse or
misapplication of material in this work. Except where otherwise stated, drug dosages
and recommendations are for the non-pregnant adult who is not
breast-feeding.
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
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.