13th Edition CHAMBERLAIN’S SYMPTOMS AND SIGNS IN CLINICAL MEDICINE An Introduction to Medical Diagnosis This page intentionally left blank 13th Edition CHAMBERLAIN’S SYMPTOMS AND SIGNS IN CLINICAL MEDICINE An Introduction to Medical Diagnosis Edited by Andrew R Houghton MA(Oxon) DM FRCP(Lond) FRCP(Glasg) Consultant Physician and Cardiologist, Grantham and District Hospital, Grantham, and Visiting Fellow, University of Lincoln, Lincoln, UK David Gray DM MPH BMedSci BM BS FRCP(Lond) FRSPH Reader in Medicine and Honorary Consultant Physician, Department of Cardiovascular Medicine, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham, UK First published in Great Britain in 1936 Second edition 1938 Third edition 1943 Fourth edition 1947 Fifth edition 1952 Sixth edition 1957 Seventh edition 1961 Eighth edition 1967 Ninth edition 1974 Tenth edition 1980 Eleventh edition 1987 Twelfth edition 1997 This thirteenth edition published in 2010 by Hodder Arnold, an imprint of Hodder Education, an Hachette Livre UK Company, 338 Euston Road, London NW1 3BH http://www.hodderarnold.com © 2010 Edward Arnold (Publishers) Ltd All rights reserved Apart from any use permitted under UK copyright law, this publication may only be reproduced, stored or transmitted, in any form, or by any means with prior permission in writing of the publishers or in the case of reprographic production in accordance with the terms of licences issued by the Copyright Licensing Agency In the United Kingdom such licences are issued by the Copyright Licensing Agency: Saffron House, 6-10 Kirby Street, London EC1N 8TS Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the editors nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed Furthermore, dosage schedules are constantly being revised and new sideeffects recognized For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book 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 ISBN-13 978 340 974 254 10 Commissioning Editor: Production Editor: Production Controller: Cover Designer: Indexer: Joanna Koster Jane Tod Kate Harris Amina Dudhia Linda Antoniw Typeset in 10 pt Minion by Phoenix Photosetting, Chatham, Kent Printed and bound in India What you think about this book? 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Please visit our website: www.hodderarnold.com Contents Instructions for companion website Preface List of contributors Chamberlain and his textbook of symptoms and signs Acknowledgements Section A - The Basics Taking a history An approach to the physical examination Devising a differential diagnosis Ordering basic investigations Medical records Presenting cases Section B - Individual Systems 10 11 12 13 14 15 16 17 18 19 20 21 The cardiovascular system The respiratory system The gastrointestinal system The renal system The genitourinary system The nervous system Psychiatric assessment The musculoskeletal system The endocrine system The breast The haematological system Skin, nails and hair The eye Ear, nose and throat Infectious and tropical diseases Section C - Special Situations 22 23 24 25 26 Assessment of the newborn, infants and children The acutely ill patient The patient with impaired consciousness The older patient Death and the dying patient Further reading Index vi vii viii x xii 11 20 23 29 35 40 82 108 137 160 185 209 233 254 269 286 306 329 351 370 390 425 434 438 458 466 467 INSTRUCTIONS FOR COMPANION WEBSITE This book has a companion website available at: http://www.hodderplus.com/chamberlainssymptomsandsigns To access the image library and multiple choice questions included on the website, please register on the website using the following access details: Serial number: kwlt294ndpxm Once you have registered, you will not need the serial number but can log in using the username and password you will create during registration Preface The student of medicine has to learn both the ‘bottom up’ approach of constructing a differential diagnosis from individual clinical findings, and the ‘top down’ approach of learning the key features pertaining to a particular diagnosis In this textbook we have integrated both approaches into a coherent working framework that will assist the reader in preparing for academic and professional examinations, and in everyday practice In so doing, we have remained true to the original intention of E Noble Chamberlain who, in 1936, wrote the following in the preface to the first edition of his textbook: As the title implies, an account has been given of the common symptoms and physical signs of disease, but since his student days the author has felt that these are often wrongly described divorced from diagnosis An attempt has been made, therefore, to take the student a stage further to the visualisation of symptoms and signs as forming a clinical picture of some pathological process In each chapter some of the commoner or more important diseases have been included to illustrate how symptoms and signs are pieced together in the jig-saw puzzle of diagnosis E Noble Chamberlain Symptoms and Signs in Clinical Medicine, 1st edition (1936) We have split this textbook into three sections The first section introduces the basic skills underpinning much of what follows – how to take a history and perform an examination, how to devise a differential diagnosis and select appropriate investigations, and how to record your findings in the case notes and present cases on ward rounds The second section takes a systems-based approach to history taking and examining patients, and also includes information on relevant diagnostic tests and common diagnoses for each system Each chapter begins with the individual ‘building blocks’ of the history and examination, and ends by drawing these elements together into relevant diagnoses A selection of self-assessment questions pertaining to each chapter is also available on the companion website so you can test what you have learnt The third and final section of the book covers ‘special situations’, including the assessment of the newborn, infants and children, the acutely ill patient, the patient with impaired consciousness, the older patient and death and the dying patient We are grateful to all of our contributors for sharing their expertise in the chapters they have written We hope that today’s reader finds the 13th edition of Chamberlain’s Symptoms and Signs in Clinical Medicine to be as useful and informative as previous generations have done since 1936 Andrew R Houghton David Gray 2010 List of contributors Guruprasad P Aithal MD PhD FRCP Consultant Hepatobiliary Physician, Nottingham Digestive Disease Centre; NIHR Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Nottingham, UK David Baldwin MD FRCP Consultant Respiratory Physician, Respiratory Medicine Unit, David Evans Centre, Nottingham University Hospitals NHS Trust, City Campus, Nottingham, UK Christine A Bowman MA FRCP Consultant Physician in Genitourinary Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK Stuart N Cohen BMedSci (Hons) MMedSci (Clin Ed) MRCP Consultant Dermatologist, Department of Dermatology, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Nottingham, UK Declan Costello MA MBBS FRCS(ORL-HNS) Specialist Registrar in Otolaryngology, Ear, Nose and Throat Department, John Radcliffe Hospital, Oxford, UK Robert N Davidson MD FRCP DTM&H Consultant Physician in Infection and Tropical Medicine, Department of Infection and Tropical Medicine, Lister Unit, Northwick Park Hospital, Harrow, Middlesex, UK Alastair K Denniston PhD MA MRCP MRCOphth Clinical Lecturer and Honorary Specialist Registrar in Ophthalmology, Academic Unit of Ophthalmology, University of Birmingham, Birmingham and Midland Eye Centre, City Hospital, Birmingham, UK Chris Dewhurst MbChB MRCPCH PgCTLCP Specialist Registrar in Neonatology, Liverpool Women’s Hospital, Liverpool, UK John S C English FRCP Consultant Dermatologist, Department of Dermatology, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Nottingham, UK Jennifer Eremin MBBS DMRT FRCR Senior Medical Researcher and Former Consultant Clinical Oncologist, United Lincolnshire Hospitals NHS Trust, Lincoln, UK Oleg Eremin MB ChB MD FRACS FRCSEd FRCST(Hon) FMedSci DSc (Hon) Consultant Breast Surgeon and Lead Clinician for Breast Services, United Lincolnshire Hospitals NHS Trust, Lincoln, UK David Gray DM MPH BMedSci BM BS FRCP(Lond) FRSPH Reader in Medicine and Honorary Consultant Physician, Department of Cardiovascular Medicine, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Nottingham, UK Alan J Hakim MA FRCP Consultant Physician and Rheumatologist, Associate Director for Emergency Medicine and Director of Strategy and Business Improvement, Whipps Cross University Hospital NHS Trust, London, UK Rowan H Harwood MA MSc MD FRCP Consultant Physician in General, Geriatric and Stroke Medicine, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Nottingham, UK Andrew R Houghton MA(Oxon) DM FRCP(Lond) FRCP(Glasg) Consultant Physician and Cardiologist, Grantham and District Hospital, Grantham, and Visiting Fellow, University of Lincoln, Lincoln, UK Martin R Howard MD FRCP FRCPath Consultant Haematologist York Hospital, and Clinical Senior Lecturer, Hull, York Medical School, Department of Haematology, York Hospital, York, UK List of contributors Prathap Kumar Kanagala MBBS MRCP Specialist Registrar in Cardiology, Department of Medicine, Grantham and District Hospital, Grantham, UK Peter Mansell DM FRCP Associate Professor and Honorary Consultant Physician, Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Nottingham, UK Philip I Murray PhD FRCP FRCS FRCOphth Professor of Ophthalmology, Academic Unit of Ophthalmology, University of Birmingham, Birmingham and Midland Eye Centre, City Hospital, Birmingham, UK Leena Patel MD FRCPCH MHPE MD Senior Lecturer in Child Health and Honorary Consultant Paediatrician, University of Manchester, Royal Manchester Children’s Hospital, Central Manchester University Hospitals Foundation Trust, Manchester, UK Hina Pattani BSc MBBS MRCP Specialist Registrar in Intensive Care and Respiratory Medicine, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Nottingham Basant K Puri MA PhD MB BChir BSc(Hons)MathSci MRCPsych DipStat PGCertMaths MMath Professor and Honorary Consultant in Imaging and Psychiatry, Hammersmith Hospital and Imperial College London, London, UK Venkataraman Subramanian DM MD MRCP Walport Lecturer, Nottingham Digestive Disease Centre: NIHR Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Nottingham, UK Peter Topham MD FRCP Senior Lecturer in Nephrology, John Walls Renal Unit, University Hospitals of Leicester, Leicester, UK Ian H Treasaden MB BS LRCP MRCS FRCPsych LLM Honorary Clinical Senior Lecturer in Psychiatry, Imperial College London, London, and Consultant Forensic Psychiatrist Three Bridges Medium Secure Unit, West London Mental Health NHS Trust, Middlesex, UK Adrian Wills BSc(Hons) MMedSci MD FRCP Consultant Neurologist, Department of Neurosciences, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Nottingham Bob Winter DM FRCP FRCA Consultant in Intensive Care Medicine, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Nottingham, UK ix TACHYCARDIAORBRADYCARDIA GALLOPRHYTHM hypotension or hypertension Neurological: s BULGINGFONTANELLE PHOTOPHOBIA MENINGISM s APATHETICDEMEANOURORALTEREDCONSCIOUSLEVEL s mOPPINESS PAUCITYOFMOVEMENTS s ABNORMALPOSTURE ARCHINGOFBACK s ALTEREDPUPILSIZEANDREACTIVITY observations of their general demeanour and behaviour However, there are many clues which can assist the novice (Table 22.13) BOX 22.5 ‘NON-ASTHMA’ FEATURES ● Wheezing and asthma ● ● ‘Wheeze’ is often used by parents and children to describe any type of noisy breathing, e.g inspiratory upper respiratory rattles in a coryzal child or stridor (Table 22.14) Ask parents to imitate the noise to clarify Young children, up to the age of years, may wheeze if they are coryzal; this is termed ‘viralinduced wheeze’ These children may continue to wheeze through childhood and develop asthma If asthma (see also Box 22.5) is suspected, check for: ● ● ● ● ● potential triggers for acute attacks – cigarette smoke, animal dander, coryza, exercise, excitement, dust, hot or cold weather, night-time the effect of asthma on the child’s life – the three S: sleep, sport and school family history of atopy (asthma, eczema, hayfever) peak flow readings in children older than 6–7 years excluding other chronic conditions such as cystic fibrosis ● ● ● Chronic productive cough with yellow or green mucus Poor weight gain Frequent offensive stools Clubbing Localized wheeze with or without crackles Poor response to bronchodilator (i.e irreversible airway obstruction) IMPORTANT Beware of the unwell child with asthma who does not have a wheeze on auscultation – ‘the silent chest’ This occurs when there is not enough air moving in and out of the lungs to generate the wheeze sound It indicates severe airway obstruction Vomiting in infants Common causes of vomiting in infants include: ● ● gastro-oesophageal reflux gastroenteritis i Common or serious paediatric presentations and diagnoses Table 22.14 Features of upper versus lower airway obstruction in children ● ● Extrathoracic or upper airway obstruction Intrathoracic or lower airway obstruction Stridor during inspiration Wheeze predominantly on expiration Suprasternal and lower sternal retraction Causes: s VIRALLARYNGOTRACHEOBRONCHITIS s EPIGLOTTITIS Intercostal and subcostal recession Causes: s ASTHMA s BRONCHIOLITIS s CYSTIClBROSIS pyloric stenosis urinary tract infections Table 22.15 Medical and surgical causes of abdominal pain Serious causes include: ● ● ● ● meningitis intestinal obstruction congenital adrenal hyperplasia metabolic disorder Acute vomiting with or without diarrhoea This is usually viral (e.g norovirus or winter vomiting viruses; rotavirus gastroenteritis) and selflimiting but can be due to other pathogens Check for: ● ● degree of dehydration – from depression of anterior fontanelle and other clinical features as in adults complications – a history of blood in the stool, pallor and child appearing unwell are warning signs of serious complications: ● haemolytic uraemic syndrome – other features are oliguria/anuria and/or petechiae/ purpura ● intussusception – typically occurs in children aged between and 12 months Vomiting is bile stained Spasms of pain when the child screams and looks pale alternate with periods when the child is exceptionally quiet and still Medical Recurrent abdominal pain Urinary tract infections Mesenteric adenitis Diabetic ketoacidosis Lower lobe pneumonia Constipation Inflammatory bowel disease Peptic ulcer disease Non-specific (nonorganic) Surgical Appendicitis Intestinal obstruction Malrotation essential to identify the minority of children who have an underlying organic cause for their pain Autistic spectrum disorder Children with autistic spectrum disorder find any changes in their routine, such as a visit to see a doctor, especially unsettling Clues from the history and observation include: ● ● ● Abdominal pain Medical and surgical causes of abdominal pain are summarized in Table 22.15 Recurrent non-specific abdominal pain occurs in around 10 per cent of children over years of age The pain is typically periumbilical, sharp, colicky and does not wake the child at night It is not associated with eating, activity, bowel habits or somatic symptoms Thorough history and examination are Acute abdominal pain ● history of an unrecognized or recognized syndrome family history – autistic spectrum disorder in a sibling restricted interest – child does not: ● engage in ‘pretend’ or imaginative play, e.g make a cup of tea with a toy tea set ● point to objects of interest in the room or a book e.g if asked, ‘Where is the teddy?’, or look at objects pointed out to them by someone else, e.g if told, ‘Look, there’s a train.’ unusual behaviour – repetitive and stereotyped movements and activities e.g ● rocking, head banging ● play with same toy or watch the same DVD ● twirl a string or wash hands repeatedly 421 Assessment of the newborn, infants and children 422 Commonly accidental over bony prominences Rarely accidental over soft tissues Forehead Face, eyes,ears Maxilla, chin Neck Shoulder Axillae Elbow Front of chest Back of forearm Abdomen Spine Lower back Iliac crest Genitalia Buttocks Thighs Knees Calf Shins Ankles Fingers and toes Figure 22.24 Distribution of bruises which are commonly accidental and rarely accidental ● ● Social interaction – ‘in a world of their own’: ● prolonged solitary play ● no awareness of children or people around them Communication abnormal or inappropriate: ● poor non-verbal skills – eye contact, facial expressions, gestures ● delayed speech ● speech repetitive, and abnormal in tone and rhythm Bruises Accidental bruises are common in normally active children They predominantly occur over bony prominences, and the pattern and distribution will be consistent with the child’s age, lifestyle and activity (Fig 22.24) When a child presents with unexplained or unusual bruises, consider two possibilities: ● bleeding disorder such as idiopathic thrombocyIMPORTANT topenic purpura, haemophilia or leukaemia – ask Attention deficit hyperactivity disorderMedicine, is an 13ED (974254) Title: Chamberlain’s Symptoms and Signs in Clinical Proofof: Stage: Fig No: 22.24 about a history inherited neurobehavioural problem Features ● easy bruising www.cactusdesign.co.uk include difficulties at school and at home The child ● frequent nose bleeds, prolonged bleeding appears disruptive, disobedient and anti-social after teeth extraction owing to: ● family history of easy bruising or unusual ● hyperactivity bleeding ● impulsive behaviour ● Non-accidental or inflicted injury, i.e physical ● difficulty paying attention abuse (Fig 22.25) i Summary Listen to the child Observe interactions History between child and parents Assess growth and development 3 & !& !*+')0 3. ! + ! + !),% ) & 3&",)0,& /($!& 2!&! &+$ !*'- )0 3 - $'(% &+ 3/($&+!'&&'+'&*!*+ &+.!+ General examination 3($ & (++ )&' ),!* * 3 )'1 &.) & **2 /() **!'&$ ** 3 & - $'(% &+' !$ ,+.+ ,$(( )& 3&(()'()!+ +!'&0) ) 3*! &*' & $ +') %'+!'&$,* 3 $0!&* #!& % !$++ &+!'& 3,&# %(+$'+ * !)' 0 &* )+! ( 3) ,* ** **% &+')%& % &+ &') !+)!* 3,&()'-'# ) **!'& 3+ ) +,) *' ,* & $ + Examination for bruises 3*!+ *'&' 0! ,) ) 3 -!',)()'$ %*')*( ! !.'))! * 3* ( ' ),!* *(++ )n ',+ !$ 3 ! ) &+'$',)* 3) -!',*!&",)! *,+%& + ! ) &+ hospitals Examination for other injuries 3%!$0& *'!$ !*+')0 3%',+ ,%*+ + ) &,$,% Record of bruises and injuries 3'+ ) !$ ) & 3 0 * ,& ! '% & 3,* ' 0 )t 3 '% *+!-!'$ & 3 &!+$! 3'+!&'&* &+& ))& ( '+' )( s 3#&'.&+''!$ )-! * 3!+ %)#*(!& %)#* 3'% !$,* ' ),!*!& 3,)&**$ *! ) ++ ,)&s 3"'!&+*& '& s Figure 22.25 Clinical assessment in a child with unexplained bruises and suspected non-accidental injury Adapted from: Ryan S, Gregg J, Patel L, Core paediatrics, with permission © 2003 London: Hodder Arnold SUMMARY General points: ● ● ● ● ● each child is unique and clinical assessment requires an individually tailored approach a neonate brings legacies from the critical period of growth and development in utero as well as the potentially hazardous process of being born problems of prematurity and congenital anomalies are major causes of morbidity in childhood and account for 60 per cent of deaths under age 15 years infants and children are more vulnerable and respond differently to certain illnesses (e.g acute infections) owing to the time taken for body systems and physiological processes such as the immune system to mature growth in size, physical changes of puberty, and neuro-behavioural, cognitive and social development occur during childhood and adolescence The basic skills in the clinical assessment of children are to: ● take a history from parents or other carers as well as from the child if the child is able to communicate ● assess the child’s growth and development ● examine the child using an age-appropriate approach ● determine whether the child is seriously ill ● identify the problems or diagnoses, predisposing/influencing factors and any complications These skills require: ● ● ● ● ● ● a holistic approach basic generic knowledge about physiology, normal variations and disease processes specific understanding about normal growth and development through childhood the ability to communicate with children and parents an understanding about how to assess children at different ages common sense 423 Assessment of the newborn, infants and children 424 i IMPORTANT Forms of child abuse include: ● physical abuse ● emotional abuse ● neglect ● sexual abuse ● fabricated illness (Munchhausen’s syndrome by proxy) FURTHER READING Arthritis Research Campaign DVD: Paediatric Gait, Arms, Legs, Spine (pGALS) Available at: www arc.org.uk/arthinfo/emedia.asp#pGALS Foster HE, Jandial S 2008 pGALS – A screening examination of the musculoskeletal system in school-aged children Arthritis Research Campaign, Reports on the Rheumatic Diseases Series 5: Hands on No 15 Available at www.arc.org.uk/ arthinfo/medpubs/6535/6535.asp (accessed 23 November 2009) Goldbloom RB 2002 Pediatric clinical skills Philadelphia: WB Saunders Ryan S, Gregg J, Patel L 2003 Core paediatrics A problem-solving approach London: Hodder Arnold UK Department of Health 2009 Spotting the sick child Available at: https://www.spottingthesickchild com 23 The acutely ill patient Hina Pattani and Bob Winter INTRODUCTION Patients in hospital may become acutely ill at any time This is more likely in certain groups of patients, for example emergency admissions, after surgical or radiological intervention and after discharge from critical care There is often a delay in recognizing and appropriately managing acutely ill patients This is likely to result in increased length of hospital stay, mortality and morbidity Abnormal physiology is often seen in patients on hospital wards; however, observations are frequently incomplete or not acted on Early warning or ‘track and trigger’ scores allocate points to observations (such as pulse and blood pressure) that are outside the normal range This weighted score can then be used to highlight such patients and trigger early assessment and treatment Acutely ill patients require prompt assessment with simultaneous treatment A systematic approach to this ensures that all immediately life-threatening problems are recognized and the correct treatment is started promptly In order to achieve this, the classical approach to assessment of the stable patient must be modified (Table 23.1) On the topic of the recognition and management of acutely ill patients, the Foundation Programme Curriculum (2007; see also Box 23.1) states that the following core competencies and skills should be acquired by foundation doctors: ● ● ● ● ● ● ● ● ● ● ● promptly assesses the acutely ill or collapsed patient identifies and responds to acutely abnormal physiology where appropriate, delivers a fluid challenge safely to an acutely ill patient reassesses ill patients appropriately after starting treatment requests senior or more experienced help when appropriate undertakes a secondary survey to establish differential diagnosis obtains an arterial blood gas sample safely, interprets results correctly manages patients with impaired consciousness, including convulsions uses common analgesic drugs safely and effectively understands and applies the principles of managing a patient following self-harm understands and applies the principles of managing a patient with an acute confusional state or psychosis Table 23.1 Patient assessment Stable patient Acutely ill patient Full history ! Systematic examination ! Investigations ! Differential diagnosis ! Management plan Immediate assessment and management (A B C D E) History and systematic examination with a review of charts and investigations ! Diagnosis and further targeted investigations ! Management plan with planned reviews of response BOX 23.1 CORE SKILLS IN RELATION TO ACUTE ILLNESS ‘On completing the two years of foundation training, all foundation doctors should be competent and feel confident in the early management of emergency patients and of those with acute problems on a background of chronic disease They will be expected to show how individual competencies can be combined to provide appropriate and timely care within the clinical settings of primary and secondary care.’ The Foundation Programme Curriculum (2007) www.foundationprogramme.nhs.uk The acutely ill patient 426 ensures safe continuing care of patients on handover between shifts, on-call staff or with ‘hospital at night’ team by meticulous attention to detail and reflection on performance considers appropriateness of interventions according to patients’ wishes, severity of illness and chronic or co-morbid diseases ● ● IMMEDIATE ASSESSMENT AND MANAGEMENT The most widely used system for assessment and treatment of acutely ill patients is the A B C D E system (Table 23.2) The rationale for this system is that conditions causing airway compromise are likely to kill more quickly than those causing breathing dysfunction and in turn those causing circulatory problems Therefore the most life-threatening problems are both identified and treated in order of priority Many of these assessments and treatments can be carried out simultaneously if more than one person is attending to the patient Table 23.2 Immediate assessment and management A Airway assessment and treatment if needed B Breathing assessment and treatment if needed C Circulation assessment and treatment if needed D Disability of the central nervous system E Exposure to allow full examination The A B C D E approach is a clinical approach, and a system of: ● ● ● ● LOOK LISTEN FEEL TREAT can be adopted for each of the components Airway The first step when assessing the airway is to talk to the patient A patient who is able to respond in an appropriate way not only has a patent airway but IMPORTANT Acutely ill patients require prompt assessment using a systematic approach to ensure that all immediately life-threatening problems are recognized and the correct treatment is initiated promptly also has adequate oxygenation, ventilation and cerebral perfusion to be able to respond appropriately Look ● Central cyanosis – purplish tinge of skin and mucus membranes due to the presence of deoxygenated haemoglobin close to the surface of the skin This occurs when oxygen saturations are below 88 per cent ● See-saw respiration – paradoxical movement of the chest and abdomen with respiratory effort On inspiration the chest is drawn in and the abdomen expands and the opposite occurs on expiration ● Use of accessory muscles of respiration – the patient may brace the shoulder girdle by resting forwards on outstretched arms ● Tracheal tug – downward tug of the trachea that is manifest by downward movement of the thyroid cartilage ● Altered level of consciousness – this can be the cause of airway compromise but can also result from airway obstruction ● Foreign bodies, blood or vomit – open the mouth to ensure it is clear Listen ● Grunting – this is an instinctive mechanism to keep the alveoli open and is caused by exhalation against a partially closed glottis ● Snoring – this is due to partial collapse or swelling of the soft tissues of the upper airway ● Hoarseness – raspy or harsh sounding voice caused by upper airway inflammation or lesions on the vocal cords ● Stridor – high-pitched inspiratory stridor is caused by airway obstruction at the level of the vocal cords Lower-pitch stridor that occurs mainly on expiration is most commonly associated with tracheal obstruction i [...]...Chamberlain and his textbook of symptoms and signs The first edition of Symptoms and Signs in Clinical Medicine: An Introduction to Medical Diagnosis was published in 1936 by John Wright & Sons (Bristol) It was written by Ernest Noble (‘Joey’) Chamberlain and included a chapter on ‘The Examination of Sick Children’ by Norman B Capon At the time his textbook was published, Chamberlain was working at the... popular, requiring a reprint within the same year, and a second edition was soon published in 1938 Further editions fol- lowed, including special Commonwealth and Japanese editions, and by the time of the eighth edition Chamberlain’s textbook had expanded to over 500 pages and was attracting great praise from a reviewer in the Archives of Internal Medicine: It is a remarkable course in diagnosis with... Start percussing in Title: Chamberlain’s Symptoms and Signs in Clinical Medicine, 13ED (974254) www.cactusdesign.co.uk Proof Stage: 1 Fig No Fig N An approach to the physical examination 18 the midline and map out the areas of dullness (fluid) and resonance (gas) Keeping the flat of your hand on the left side of the abdomen, with your middle finger demarcating the border between dullness and resonance,... patient dignity and the need for a chaperone The core competencies and skills listed in the Curriculum are given below F1 level: ● explains the examination procedure, gains appropriate consent for the examination and minimizes patient discomfort An approach to the physical examination 12 ● ● elicits individual clinical signs and adopts a coordinated approach to target detailed examination as suggested... assessing the patient’s conditions, taking account of the history (including the symptoms, and psychological and social factors), the patient’s views, and where necessary examining the patient ● providing or arranging advice, investigations or treatment where necessary ● referring a patient to another practitioner, when this is in the patient’s best interests physical problems on psychological and social... obliterated in prostatic hypertrophy or hard and nodular in prostatic cancer the cervix in women from the patient’s movements during the clinical examination Start with the cranial nerves, and then examine the peripheral nervous system; these are described in detail in Chapter 12 The above is an outline of a basic clinical examination which will suffice for most patients There are many other signs that... outcomes and (when available) the results recognizes normal and abnormal results in adults prioritizes importance of results and asks for appropriate help ensures results are available and timely F2 level: ● ● supports F1 doctors or students in requesting, interpreting and acting on the results of common investigations understands local systems and asks for appropriate help Confirming and excluding diagnoses... haematological systems (Chapter 17) FURTHER READING Douglas G, Nicol F, Robertson C 2009 Macleod’s clinical examination, 12th edn Edinburgh: Churchill Livingstone Epstein O, Perkin GD, Cookson J, et al 2008 Clinical examination, 4th edn London: Mosby Talley NJ, O’Connor S 2005 Clinical examination: a systematic guide to physical diagnosis, 5th edn Edinburgh: Churchill Livingstone The Foundation Programme Curriculum,... clue that things weren’t quite right? What happened next? On the topic of diagnosis and clinical decisionmaking, the Foundation Programme Curriculum (2007) states that foundation doctors should demonstrate knowledge of the principles of clinical reasoning in medicine Foundation doctors should understand the impact on differential diagnosis of the different clinical settings of primary and secondary... From: Gray D, Toghill P (eds), An introduction to the symptoms and signs of clinical medicine, with permission © 2001 London: Hodder Arnold (a) well defined – use your fingertips to define the liver edge more accurately (Fig 2.1b) The surface in disease may be hard, tender and irregular and occasionally pulsatile in tricuspid regurgitation Kidneys The kidneys move down on inspiration; the left is more .. .13th Edition CHAMBERLAIN’S SYMPTOMS AND SIGNS IN CLINICAL MEDICINE An Introduction to Medical Diagnosis This page intentionally left blank 13th Edition CHAMBERLAIN’S SYMPTOMS AND SIGNS IN CLINICAL. .. Campus, Nottingham, UK ix Chamberlain and his textbook of symptoms and signs The first edition of Symptoms and Signs in Clinical Medicine: An Introduction to Medical Diagnosis was published in 1936... sharing their expertise in the chapters they have written We hope that today’s reader finds the 13th edition of Chamberlain’s Symptoms and Signs in Clinical Medicine to be as useful and informative