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 Library of Congress Cataloging in Publication Data 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. 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The publisher’s policy is to use paper manufactured from sustainable forests Working together to grow libraries in developing countries www.elsevier.com | www.bookaid.org | www.sabre.org Printed in China 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 This page intentionally left blank 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 This page intentionally left blank 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. This page intentionally left blank Principles of clinical assessment What’s in a diagnosis?...........................................3 Assessing patients: a practical guide....................7 The diagnostic process........................................19 1 PART This page intentionally left blank