Macleods clinical diagnosis 2013

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 Macleod’s Alan G Japp MBChB(Hons) BSc(Hons) MRCP Cardiology Registrar Royal Inirmary 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 Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto Clinical Diagnosis Edited by © 2013 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 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 ield 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 With respect to any drug or pharmaceutical products identiied, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the publisher nor the authors, contributors, or editors, assume any liability 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 Working together to grow libraries in developing countries www.elsevier.com | www.bookaid.org | www.sabre.org Printed in China The publisher’s policy is to use paper manufactured from sustainable forests Preface ‘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 ‘disconnect’ between the importance ascribed to basic clinical skills during teaching and the apparent reliance on sophisticated investigations in the parallel world of clinical practice Modern diagnostics have radically 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 assessment 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 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 lags, identifying unsuspected problems and, in some cases, revealing signs that cannot be identiied 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 investigation However, we also highlight those instances where diagnosis is critically dependent on basic clinical assessment, thereby demonstrating its vital and enduring 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 v Acknowledgements 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 encouragement, optimism and extraordinary patience throughout the long months of writing and editing AJ Figure sources 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 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 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 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 6.3: Grubb NR, Newby DE Churchill’s Pocketbooks Cardiology, 2nd edn Edinburgh: Churchill Livingstone, 2006 Fig 26.3: Kumar P, Clark M Kumar and Clark Clinical Medicine, 7th edn Edinburgh: Churchill Livingstone, 2009 Figs 6.6, 6.8, 25.2: Hampton JR The ECG Made Easy, 7th edn Edinburgh: Churchill Livingstone, 2008 Figs 26.5, 26.8, 26.9, 26.10: Bolognia J, Jorizzo J, Rapini R Dermatology, 1st edn London: Mosby, 2003 Contributors R Benjamin Aldridge Colin Mitchell MBChB MSc MRCP MRCS MBChB MRCP Clinical Research Fellow in Dermatology, University of Edinburgh; Specialty Registrar in Plastic and Reconstructive Surgery, Canniesburn Unit, Glasgow Royal Inirmary, UK Consultant Geriatrician, St Mary’s Hospital, London, UK Roland C Aldridge Jonathan C L Rodrigues BSc(Hons) MBChB(Hons) MRCP(UK) Specialist Registrar in Clinical Radiology, Severn School of Radiology, Bristol, UK MSc MRCS MRCP Clinical Lecturer, University of Edinburgh; Honorary Specialty Registrar in General Surgery, South East Scotland, Edinburgh, UK J Kenneth Baillie Lynn M Urquhart MBChB, MRCP, DTMH Specialty Registrar in Infectious Diseases and Clinical Research Fellow Medical Education, Ninewells Hospital and Medical School, Dundee, UK BSc(Hons) MRCP FRCA Clinical Lecturer, Department of Critical Care Medicine, University of Edinburgh, Edinburgh, UK Xavier L Grifin Hugh B Waterson MRCSEd Specialist Registrar Trainee in Orthopaedics, Royal Inirmary of Edinburgh, Edinburgh, UK MA MSc MRCS Specialist Registrar in Trauma and Orthopaedic Surgery, Warwick Medical School, University of Warwick, Warwick, UK vii This page intentionally left blank Contents Abbreviations xi Part Principles of clinical assessment What’s in a diagnosis? Assessing patients: a practical guide The diagnostic process 19 Part Assessment of common presenting problems Abdominal pain 26 Breast lump 44 Chest pain 48 Coma and altered consciousness 70 Confusion: delirium and dementia 76 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 ix APPENDIX Normal values for biochemical tests in venous blood Reference range Analyte SI units Non-SI units Alanine amino-transferase (ALT) Albumin Alkaline phosphatase (ALP) Aspartate amino-transferase (AST) Bilirubin (total) Calcium (total) 10–50 U/L 35–50 g/L 40–125 U/L 10–45 U/L – 3.5–5.0 g/dL – – 2–17 µmol/L 2.12–2.62 mmol/L Chloride Cholesterol (total) 0.12–1.0 mg/dL 4.24–5.24 meq/L or 8.50–10.50 mg/dL 95–107 meq/L 200–250 mg/dL 250–300 mg/dL >300 mg/dL 22–30 meq/L 95–107 mmol/L Mild increase 5.2–6.5 mmol/L Moderate increase 6.5–7.8 mmol/L Severe increase >7.8 mmol/L 22–30 mmol/L [...]... of clinical assessment What’s in a diagnosis? 3 Assessing patients: a practical guide 7 The diagnostic process 19 This page intentionally left blank WHAT’S IN A DIAGNOSIS? From differential diagnosis to inal diagnosis A diagnosis is simply shorthand for a patient’s condition or disease process The ability to diagnose accurately is fundamental to clinical practice Only with a correct diagnosis, ... The clinical examination A routine ‘screening’ clinical examination (see Clinical tool: The 20-step clinical examination) is required in most patients Some elements of the clinical examination that have traditionally been considered routine are only required in speciic circumstances These include examination of the fundi, rectum, genitalia, breasts and individual joints Clinical tool: The 20-step clinical. .. not in a recognised at-risk group, and there are no abnormalities on clinical examination and simple bedside tests (Fig 1.1 and Box 1.1) WHAT’S IN A DIAGNOSIS? Treatment before diagnosis Table 1.1 Common functional syndromes1 Syndrome Symptoms Chronic fatigue syndrome Irritable bowel syndrome Persistent fatigue2 Sometimes, accurate diagnosis depends upon the patient’s response to treatment In a few... these simple tests should be carried out in tandem with the clinical assessment to form a ‘routine patient workup’ The information from all of these sources is combined to form a working or differential diagnosis Where necessary, further targeted investigation can then be undertaken to conirm the suspected diagnosis, narrow the differential diagnosis e.g exclude high-risk conditions, inform prognosis... tissue diagnosis and stage the tumour The eventual ‘inal diagnosis might be: irondeiciency anaemia secondary to blood loss from a T3, N1, M1 gastric carcinoma with metastasis to liver and peritoneum Clearly, the diagnosis of ‘anaemia’ would have been grossly inadequate! Some conditions, especially functional disorders such as irritable bowel syndrome, lack a deinitive conirmatory test; here diagnosis. .. physical examination and interpret basic tests The next stage is to translate the resulting raw clinical data into a diagnosis The primary aim of this book is to show you how this can be achieved Diagnostic methods The exact method by which a diagnosis is reached may seem somewhat mysterious to newcomers to clinical medicine The best diagnosticians invariably use several complementary skills which have... most likely cause of the patient’s presentation, it is often referred to as the working diagnosis Investigations are then directed toward conirming (or refuting) this condition and thereby arriving at a final diagnosis This entire process may happen over a very short period of time; for example, establishing a inal diagnosis of acute ST elevation myocardial infarction in a patient presenting with acute... ‘pain ladder’ approach is useful, but for patients in acute or severe pain, IV opioids titrated to the clinical response are usually needed The patient who comes with a diagnosis Many patients have an idea of their own condition and, indeed, may begin the consultation by telling you their perceived diagnosis In part this relates to improved education, greater exposure to medical conditions through the... disease, will often present in this way Remember that many patients will be worrying about a speciic diagnosis causing their presenting complaint This is particularly the case for breast lumps, rectal bleeding and chronic headache, where the perception may be that the only possible diagnosis is cancer Self -diagnosis may also cause a delay in seeking medical help because the patient does not appreciate... differential diagnosis is a stepping-stone to the inal diagnosis This is a list of diagnoses, usually placed in order of likelihood, which may be causing the presentation This list may be lengthy at the outset of assessment but will become progressively shorter as you accumulate information about the patient’s condition through your historytaking, examination and investigations When one diagnosis begins