Any screen. Any time. Anywhere. Activate the eBook version of this title at no additional charge. Student Consult eBooks give you the power to browse and find content, view enhanced images, share notes and highlights—both online and offline. Unlock your eBook today. 1 Visit studentconsult.inkling.com/redeem Scan this QR code to redeem your eBook through your mobile device: 2 Scratch off your code 3 Type code into “Enter Code” box 4 Click “Redeem” 5 Log in or Sign up 6 Go to “My Library” It’s that easy! Place Peel Off Sticker Here For technical assistance: email [email protected] call 1-800-401-9962 (inside the US) call +1-314-447-8200 (outside the US) Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on studentconsult.inkling.com. Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book, at studentconsult.inkling.com and may not be transferred to another party by resale, lending, or other means. 2015v1.0 Macleod’s Clinical Examination John Macleod (1915–2006) John Macleod was appointed consultant physician at the Western General Hospital, Edinburgh, in 1950. He had major interests in rheumatology and medical education. Medical students who attended his clinical teaching sessions remember him as an inspirational teacher with the ability to present complex problems with great clarity. He was invariably courteous to his patients and students alike. He had an uncanny knack of involving all students equally in clinical discussions and used praise rather than criticism. He paid great attention to the value of history taking and, from this, expected students to identify what particular aspects of the physical examination should help to narrow the diagnostic options. His consultant colleagues at the Western welcomed the opportunity of contributing when he suggested writing a textbook on clinical examination. The book was first published in 1964 and John Macleod edited seven editions. With characteristic modesty he was very embarrassed when the eighth edition was renamed Macleod’s Clinical Examination. This, however, was a small way of recognising his enormous contribution to medical education. He possessed the essential quality of a successful editor – the skill of changing disparate contributions from individual contributors into a uniform style and format without causing offence; everybody accepted his authority. He avoided being dogmatic or condescending. He was generous in teaching others his editorial skills and these attributes were recognised when he was invited to edit Davidson’s Principles and Practice of Medicine. Content Strategist: Laurence Hunter Content Development Specialist: Helen Leng Project Manager: Anne Collett Designer: Miles Hitchen Illustration Manager: Karen Giacomucci Macleod’s 14th Edition EC Edited by x l J Alastair Innes i BSc PhD FRCP(Ed) a Consultant Physician, Respiratory Unit, Western General n Hospital, Edinburgh; Honorary Reader in Respiratory Medicine, University of Edinburgh, UK m Anna R Dover i PhD FRCP(Ed) c Consultant in Diabetes, Endocrinology and General Medicine, Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh; Honorary Clinical Senior Lecturer, i a University of Edinburgh, UK n Karen Fairhurst PhD FRCGP l General Practitioner, Mackenzie Medical Centre, Edinburgh; a Clinical Senior Lecturer, Centre for Population Health Sciences, University of Edinburgh, UK t Illustrations by Robert Britton and Ethan Danielson i o n Edinburgh London New York Oxford Philadelphia St Louis Sydney 2018 © 2018 Elsevier Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the publisher (other than as may be noted herein). First edition 1964 Sixth edition 1983 Eleventh edition 2005 Second edition 1967 Seventh edition 1986 Twelfth edition 2009 Third edition 1973 Eighth edition 1990 Thirteenth edition 2013 Fourth edition 1976 Ninth edition 1995 Fourteenth edition 2018 Fifth edition 1979 Tenth edition 2000 ISBN 978-0-7020-6993-2 International ISBN 978-0-7020-6992-5 Notices Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. The publisher’s policy is to use paper manufactured from sustainable forests Printed in Europe Last digit is the print number: 9 8 7 6 5 4 3 2 1 Contents Preface vii Acknowledgements ix How to make the most of this book xi Clinical skills videos xiii Contributors xv SECTION 1 PRINCIPLES OF CLINICAL HISTORY AND EXAMINATION 1 1 Managing clinical encounters with patients 3 Karen Fairhurst, Anna R Dover, J Alastair Innes 2 General aspects of history taking 9 J Alastair Innes, Karen Fairhurst, Anna R Dover 3 General aspects of examination 19 Anna R Dover, J Alastair Innes, Karen Fairhurst SECTION 2 SYSTEM-BASED EXAMINATION 37 4 The cardiovascular system 39 Nicholas L Mills, Alan G Japp, Jennifer Robson 5 The respiratory system 75 J Alastair Innes, James Tiernan 6 The gastrointestinal system 93 John Plevris, Rowan Parks 7 The nervous system 119 Richard Davenport, Hadi Manji 8 The visual system 151 Shyamanga Borooah, Naing Latt Tint 9 The ear, nose and throat 171 Iain Hathorn 10 The endocrine system 193 Anna R Dover, Nicola Zammitt 11 The reproductive system 211 Oliver Young, Colin Duncan, Kirsty Dundas, Alexander Laird vi • Contents 12 The renal system 237 Neeraj Dhaun, David Kluth 13 The musculoskeletal system 251 Jane Gibson, Ivan Brenkel 14 The skin, hair and nails 283 Michael J Tidman SECTION 3 APPLYING HISTORY AND EXAMINATION SKILLS IN SPECIFIC SITUATIONS 295 15 Babies and children 297 Ben Stenson, Steve Cunningham 16 The patient with mental disorder 319 Stephen Potts 17 The frail elderly patient 329 Andrew Elder, Elizabeth MacDonald 18 The deteriorating patient 339 Ross Paterson, Anna R Dover 19 The dying patient 347 Anthony Bateman, Kirsty Boyd SECTION 4 PUTTING HISTORY AND EXAMINATION SKILLS TO USE 353 20 Preparing for assessment 355 Anna R Dover, Janet Skinner 21 Preparing for practice 361 Karen Fairhurst, Gareth Clegg Index 375 Preface Despite the wealth of diagnostic tools available to the modern to the use of pattern recognition to identify spot diagnoses. physician, the acquisition of information by direct interaction Section 2 deals with symptoms and signs in specific systems with the patient through history taking and clinical examination and Section 3 illustrates the application of these skills to specific remains the bedrock of the physician’s art. These time-honoured clinical situations. Section 4 covers preparation for assessments skills can often allow clinicians to reach a clear diagnosis without of clinical skills and for the use of these skills in everyday practice. recourse to expensive and potentially harmful tests. An expertly performed history and examination of a patient This book aims to assist clinicians in developing the consultation allows the doctor to detect disease and predict prognosis, and is skills required to elicit a clear history, and the practical skills crucial to the principle of making the patient and their concerns needed to detect clinical signs of disease. Where possible, the central to the care process, and also to the avoidance of harm physical basis of clinical signs is explained to aid understanding. from unnecessary or unjustified tests. Formulation of a differential diagnosis from the information gained We hope that if young clinicians are encouraged to adopt is introduced, and the logical initial investigations are included for and adapt these skills, they not only will serve their patients each system. Macleod’s Clinical Examination is designed to be as diagnosticians but also will themselves continue to develop used in conjunction with more detailed texts on pathophysiology, clinical examination techniques and a better understanding of differential diagnosis and clinical medicine, illustrating specifically their mechanisms and diagnostic use. how the history and examination can inform the diagnostic The 14th edition of Macleod’s Clinical Examination has an process. accompanying set of videos available in the online Student In this edition the contents have been restructured and the Consult electronic library. This book is closely integrated with text comprehensively updated by a team of existing and new Davidson’s Principles and Practice of Medicine and is best read authors, with the aim of creating an accessible and user-friendly in conjunction with that text. text relevant to the practice of medicine in the 21st century. Section 1 addresses the general principles of good interaction JAI, ARD, KF with patients, from the basics of taking a history and examining, Edinburgh, 2018 This page intentionally left blank