Textbook of Physical Diagnosis with DVD: History and Examination With STUDENT CONSULT Online Access

909 Pages·2009·21.04 MB·English

by  Mark H. Swartz

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Textbookofphysicaldiagnosis:historyandexamination/MarkHSwartz.–6thed.
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Includesbibliographicalreferencesandindex.
ISBN978-1-4160-6203-5
1.Physicaldiagnosis–Textbooks.I.Title.
[DNLM:1.Diagnosis.2.MedicalHistoryTaking.3.PhysicalExamination.WB200S973t2010]
RC76.S952010
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2008029911
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One of the essential qualities of the clinician is interest in humanity,
for the secret in the care of the patient is in caring for the patient.
Francis Weld Peabody (1881–1927)
To Vivian Hirshaut, MD,
my wife, my life’s companion and my best friend, for her
love, support, and understanding;
To Talia H. Swartz, MD, PhD,
my wonderful and devoted daughter;
To the memory of my parents, Hilda and Philip;
and
To my students, from whom I am always learning.
Preface to the Sixth Edition
TextbookofPhysicalDiagnosis:HistoryandExaminationhasbeenwrittenforstudentsof
health care who are learning to communicate effectively with patients, to examine
patients, and to assess their medical problems. Although 20 years have passed since
thepublicationofthefirstedition,thistextstilloffersauniqueapproachtophysical
diagnosis.Bydiscussingpathophysiologyofdiseaseandemphasizingthehumanistic
element of health care, I attempt to show the importance of the ‘‘old-fashioned’’
doctor’s approach to the patient. ‘‘The primary aim of this textbook,’’ as stated in
thePrefacetotheFirstEdition,‘‘istoprovideaframeworkfortheclinicalassessment
of the patient in a humanistic manner.’’ The book, then and now, focuses on the
patient: his or her needs, problems, and concerns.
Thehistoryandphysicalexaminationmustnotbeseenasproceduresperformed
by a robot but rather as a process that requires interpersonal awareness as well as
technical skill. In this era of extraordinary advances in diagnostic modalities, proce-
dures and tests have been emphasized, while the importance of the history and
physical examination has been minimized. It is well known, however, that among
the most valuable and least costly medical evaluations are the history and physical
examination.Thisbookfocusesonhowtoofferthebestmedicalcarethroughtheart
of interviewing and physical examination.
The Sixth Edition represents a major revision based on a complete review of the
field of physical diagnosis. The chapters have been reviewed and modified where
appropriate. Extensive changes have been made to the pediatric chapter and to the
chapter on the pregnant patient. As times change, so do standards of physical diag-
nosis. Therefore, several of the tests indicated in the previous editions have been
either modified or eliminated. The bibliography has been updated. This edition
includes a new chapter on the focused history and physical examination, since this
skillissoimportanttodaywiththeintroductionoftheUSMLEStep2CSexamination.
AnotherfeatureofthiseditionistheinclusionofaDVD-ROMthatcontainsstep-
by-stepdemonstrations ofthecompletephysicalexaminationofthemanandofthe
breast and pelvic examinations of the woman. The DVD-ROM, playable on your
computer as well as on a DVD player, also illustrates the pediatric examinations of
thenewbornandofthetoddler,aswellasanewsectionontheneurologicevaluation
ofthetoddler.Usingstandardizedpatients,theDVD-ROMshowshistory-takingwith
anadolescentandhermother,aswellasinterviewingtechniquesregardingsensitive
topics with a geriatric patient. These sensitive topics include a discussion of advance
directives (i.e., health care proxy determination and living wills), a mental status
examination of a patient with cognitive impairment, and a scenario showing how
togivebadnews.Inaddition,thisneweditionalsocontainsscenariosdemonstrating
thefocused history andphysical examination of ayoung man withabdominal pain,
ix
x Prefaceto the SixthEdition
counseling a woman about health-related issues, and a demonstration of a pediatric
telephone consultation. The DVD-ROM coupled with the textbook provide a com-
prehensiveclinicalreferencefortheunderstandingoftheorganizationandfluidityof
the complete assessment of the patient.
Thebookisrichlyillustratedwithover900photographsandlineart.Manyofthe
original black-and-white images demonstrating the techniques of the examination
have been replaced with color images captured from the DVD-ROM videos.
In addition, this Sixth Edition includes an accompanying website on Student
Consult, which is an online interactive learning platform presenting a collection of
over 50 Elsevier textbook titles with a wide array of ancillary materials. The website
features fully searchable text; integration links that will seamlessly connect the user
to additional and related content in other Student Consult titles; an image library,
with figures that can be easily downloaded into PowerPoint; and supplementary
material such as audio clips. Users can gain access to the online version of this
book by going to www.studentconsult.com and entering the unique PIN code pro-
vided on the inside front cover of this book.
Thehealthcareprovideroftodaymustbeabletosynthesizebasicpathophysiol-
ogy with humanistic medical care. As the medical profession continues to be under
greatscrutiny,wemustemphasizeanempatheticapproachtopatientcare,recogniz-
ing the role of culture in illness and using modern technology only to enhance our
clinical assessment, not to replace it. We must always remember that a patient is a
person suffering from disease.
I hope that you will find this Sixth Edition of Textbook of Physical Diagnosis:
History and Examination to be reader-friendly, comprehensive, and an exciting addi-
tion to your library.
Mark H. Swartz, MD, FACP
Acknowledgments
Iwishtoacknowledgeallofmyprofessionalcolleaguesandfriendswhohavesupportedandguided
me in writing this Sixth Edition. I express my heartfelt thanks to the following people, without
whoseassistanceIcouldnothavebroughtthisbooktoareality:
Toallmyteachers,students,andpatientswhohavetaughtmesomuchaboutmedicine.
Specialthankstothefollowingpeoplewhohavehelpedinreviewingchaptersforthisedition:
JerryA.Colliver,PhD RobertW.Marion,MD
FormerDirectorofStatisticsandResearch ProfessorofPediatricsandObstetrics
ConsultingandProfessorofMedical andGynecology
Education(1981–2007) RuthL.GottesmanProfessorof
SouthernIllinoisUniversitySchoolofMedicine ChildDevelopment
Springfield,Illinois DirectoroftheChildren’sEvaluation
andRehabilitationCenter
MargaretClarkGolden,MD
Co-Director,MedicalStudentEducation,
ClinicalAssociateProfessorofPediatrics
DepartmentofPediatrics
Director,ThirdYearPediatricClerkship
AlbertEinsteinCollegeofMedicine
DepartmentofPediatrics
Co-Chief,SectionofGenetics,andDirector,
StateUniversityofNewYork(SUNY)
CenterforCongenitalDisorders
DownstateCollegeofMedicine
Children’sHospitalatMontefiore
Brooklyn,NewYork
Bronx,NewYork
MarkKosinski,DPM
MimiMcEvoy,RN,CPNP,MA
ProfessorofMedicine
AssistantProfessorofPediatrics
NewYorkCollegeofPodiatricMedicine
AlbertEinsteinCollegeofMedicine
NewYork,NewYork
Bronx,NewYork
InstructorofSurgery
NewYorkMedicalCollege JoannaF.Shulman,MD
Valhalla,NewYork AssistantProfessorofObstetricsand
Gynecology
RobertKushner,MD
Director,ThirdYearOB/GYNClerkship
ProfessorofMedicine
DepartmentofObstetrics,Gynecology&
NorthwesternUniversityFeinbergSchool
ReproductiveScience
ofMedicine
MountSinaiSchoolofMedicine
Chicago,Illinois
NewYork,NewYork
TaliaH.Swartz,MD,PhD
DepartmentofInternalMedicine
MountSinaiMedicalCenter
NewYork,NewYork
xi
xii Acknowledgments
Andtothefollowingpeoplewhohelpedinpreviouseditions:
JamesR.Bonner,MD SheldonJacobson,MD
DennisW.Boulware,MD MountSinaiSchoolofMedicine
UniversityofAlabamaSchoolofMedicine NewYork,NewYork
Birmingham,Alabama
PeterB.Liebert,MD
GabrieleChryssanthou,CO MountSinaiSchoolofMedicine
NewYork,NewYork NewYork,NewYork
TracieL.DeMack MerylH.Mendelson,MD
UniversityofChicagoSchoolofMedicine MountSinaiSchoolofMedicine
Chicago,Illinois NewYork,NewYork
EthanD.Fried,MD
ColumbiaUniversityCollegeofPhysicians
andSurgeons
NewYork,NewYork
Andfinally,specialthanks:
ToWendyBethJackelow,whohasartisticallyillustratedalleditionsofthisbook.
ToFrederickS.Bobrowforhistireless effortsto expertlyproduce theDVD-ROM inthisbook,as
wellastheDVD-ROMandCD-ROMinearliereditions.
ToMargaretClarkGolden,MD,forallofhertimeandhelpinpreparingthepediatricandadolescent
portionsoftheDVD-ROM.Dr.GoldenwishestoacknowledgewiththanksDr.RobertLouisGatson,
whotaughtherwhatitmeanstobeapediatrician.
To Ella-Jean L. Richards-Franc¸ois, MD, for preparing the adolescent history portion of the
DVD-ROM.
ToJoanKendall,MegAnderson,LilyBurd,TomPennacchini,SandraParris,andLaneBinkley,who
weretheremarkableactorsportrayingthepatientsintheDVD-ROM.
To the many employees at Elsevier for their expert assistance and cooperation. In particular, I
would like to acknowledge the help of James Merritt, my editor, and the production team of
ChristineAbshire, Sharon Lee,Lou Forgione, DavidRushing,andLisa Damico, whoseefforts have
beencriticalintheplanning,production,design,media,andmarketingofthisedition.
And finally to my wife, Vivian Hirshaut, for her personal support, endless patience, and under-
standing.Withoutherboundlessaffection,indefatigablehelp,sustaineddevotion,andencourage-
ment,thisbookcouldneverhavecometofruition.
Mark H. Swartz, MD, FACP
Photograph Credits
Aphotographmakesaconceptordiseaseentitymoreunderstandableandeasiertorecognize.Asthe
well-known proverb says, ‘‘A picture is worth a thousand words.’’ I wish to acknowledge with deep
gratitude the following colleagues who have graciously allowed me to use slides from their own
teachingcollectionstohelpillustratethisSixthEdition.
BrianM.Kabcenell,DMD
RyeDentalAssociates,PC
Rye,NewYork
(Figure12-37A)
MarkKosinski,DPM
NewYorkCollegeofPediatricMedicine
NewYork,NewYork
(Figure10-58)
Thefollowingindividualswerekindenoughtocontributetheirslidestopreviouseditions:
J.DanielArbour,MD KarenAnnKlima,BA,CRA,COMT
MarcBlouin,DEC,OA MarkA.Kosinski,DPM
AndrewH.Eichenfield,MD WilliamLawson,MD
StephenA.Estes,MD AlanB.Levine,DC
NeilA.Fenske,MD ThomasP.Link,CRA
RaulFleischmajer,MD HarryLumerman,DDS
PeterT.Fontaine,CRA,EMT BryanC.Markinson,DPM
HowardFox,DPM MichaelA.Rothschild,MD
AlanFriedman,MD DonaldRudikoff,MD
BecharaY.Ghorayeb,MD BenSerar,M.A.,CRA
AlejandraGurtman,MD DeborahL.Shapiro,MD
MichaelHawke,MD MichaelStanley
DonaldE.Hazelrigg,MD ArthurSteinhart,DPM
GregoryC.Hoffmeyer PhillipA.Wackym,MD
AnthonyIorio,DPM,MPH JosephB.Walsh,MD
BrianM.Kabcenell,D.M.D. KatherineWard,DPM
MichaelP.Kelly
Iwishtoacknowledgewiththankstheauthorsandpublishersofthefollowingbooksforpermission
toreprintfiguresfromtheirtexts:
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Lange,1980. Mosby,1998.
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5–7B,5–8,8–6B,8–8,8–16AB,8–26B,8–29,8–43, 12–3,12–4,12–18,12–34,12–37A,12–43,12–47,
8–48,8–58,8–59,8–61,8–64B,8–65,8–70,8–71, 12–48, 12–49, 12–57, 24–42: From Eisen D,
8–73, 8–75, 8–78, 8–81, 8–82, 8–87, 8–88, 8–90, Lynch DP: The Mouth: Diagnosis and
8–99,8–102,8–104,8–106,8–109,8–112,12–13, Treatment.St.Louis,Mosby,1998.
12–50,14–15,15–2,18–8,18–9,18–10,18–14A,
12–12, 24–7, 24–11, 24–27, 24–31, 24–53: From
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Cohen BA: Atlas of Pediatric Dermatology.
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Philadelphia,WBSaunders,2000. Oral Manifestations of AIDS, 2nd ed. St. Louis,
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CHAPTER 1
The Interviewer’s Questions
What is spoken of as a ‘‘clinical picture’’ is not just a photograph of a man sick in bed;
it is an impressionistic painting of the patient surrounded by his home, his work,
his relations, his friends, his joys, sorrows, hopes and fears.
Francis Weld Peabody (1881–1927)
Basic Principles
Goodcommunicationskillsarethefoundationofexcellentmedicalcare.Evenwiththeexcit-
ingnewtechnologythathasappearedsince2000,communicativebehaviorisstillparamount
in the care of patients. Studies have shown that good communication improves health out-
comes by resolving symptoms and reducing patients’ psychological distress and anxiety.
Technologicmedicinecannotsubstituteforwordsandbehaviorinservingtheill.Thequality
of patient care depends greatly on the skills of interviewing, because the relationship that a
patient has with a physician is one of the most extraordinary relationships between two
humanbeings.Withinamatterofminutes,twostrangers—thepatientandthehealer—begin
to discuss intimate details about a person’s life. Once trust is established, the patient feels at
ease discussing the most personal details of the illness. Clearly, a strong bond, a therapeutic
alliance, has tohavebeenestablished.
Themainpurposeofaninterviewistogatherallbasicinformationpertinenttothepatient’s
illnessandthepatient’sadaptationtoillness.Anassessmentofthepatient’sconditioncanthen
bemade.Anexperiencedinterviewerconsidersalltheaspectsofthepatient’spresentationand
thenfollowstheleadsthatappeartomeritthemostattention.Theinterviewershouldalsobe
aware of the influence of social, economic, and cultural factors in shaping the nature of the
patient’sproblems.Otherimportantaspectsoftheinterviewareeducatingthepatientaboutthe
diagnosis,negotiatingamanagementplan,andcounselingaboutbehavioralchanges.
Anypatient who seeksconsultation from aclinicianneedstobeevaluated inthebroadest
sense. The clinician must be keenly aware of all clues, obvious or subtle. Although body lan-
guageisimportant,thespokenwordremainsthecentraldiagnostictoolinmedicine.Forthis
reason,theartofspeakingandlisteningcontinuestobethecentralpartofthedoctor-patient
interaction.Onceallthecluesfromthehistoryhavebeengathered,theassimilationofthose
cluesintoan ultimate diagnosis isrelatively easy.
Communication is the key to a successful interview. The interviewer must be able to ask
questionsofthepatientfreely.Thesequestionsmustalwaysbeeasilyunderstoodandadjusted
to the medical sophistication of the patient. If necessary, slang words describing certain
conditions maybeused tofacilitate communication and avoidmisunderstanding.
Health care providers are increasingly treating patients across language barriors. For any
patient who speaks a language other than that of the clinician, it is important to seek the
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