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2020_PC
Evidence-Based
Physical Diagnosis
EDITION 5
Evidence-Based
Physical Diagnosis
STEVEN McGEE, M.D.
Professor Emeritus, Medicine
University of Washington School of Medicine
lsevier
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E
1600 John F. Kennedy Blvd.
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Philadelphia, PA 19103-2899
EVIDENCE-BASED PHYSICAL DIAGNOSIS,
FIFTH EDITION
Copyright © 2022 by Elsevier, Inc. 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.
is book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
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.
ISBN: 9780323754835
Previous editions copyrighted 2018, 2012, and 2007.
Library of Congress Control Number: 2021941821
Content Strategist: Charlotta Kryhl
Content Development Specialist: Kathryn DeFrancesco
Publishing Services Manager: Deepthi Unni
Project Manager: Radjan Lourde Selvanadin
Design Direction: Renee Duenow
Printed in the United States of America.
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To Rosalie, Connor, and Matt
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PREFACE TO THE FIFTH EDITION
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Since the appearance of the fourth edition of this work, hundreds of new studies on physical
diagnosis have appeared, and research has further defined how physical findings help identify
disease, solve clinical problems, and forecast patient outcomes. In this fifth edition of Evidence-
Based Physical Diagnosis, 203 of these new studies have been added to the Evidence-Based Medicine
(EBM) Boxes, thus providing the most up-to-date summary of physical examination and its diag-
nostic accuracy. New references have replaced outworn ones, although classic articles and original
descriptions remain. Every chapter has been updated. Many findings not previously addressed
in prior editions appear here, along with their diagnostic accuracy and likelihood ratios. ese
findings include the Romberg test (spinal stenosis); oximeter paradoxus (cardiac tamponade);
platypnea (liver disease); relative afferent pupil defect (unilateral visual loss); pupil size in red eye
(acute glaucoma); hum test (hearing loss); jolt accentuation headache (meningitis); nasal flaring,
intercostal retractions, and suprasternal retractions (dyspnea); diastolic rumble (mitral stenosis);
bendopnea test (congestive heart failure); hand vein estimates of central venous pressure; adenopathy (infectious mononucleosis); abnormal bowel tones (recovery from postoperative ileus);
Ipswich touch test (diabetic foot); the Edinburgh algorithm for diplopia; and the bedside diagnosis of orbital fractures. As in the last edition, each chapter begins with a list of Key Teaching Points,
intended for individuals desiring quick summaries and for teachers constructing concise bedside
lessons. Each EBM Box remains linked to the Elsevier online EBM calculator to quickly estimate
post-test probability using the likelihood ratios in each chapter.
I am grateful to many investigators who supplied me with unpublished information from
their original work: Bastiaan Bloem, Jorik Nonnekes, and W.F. Abdo (tandem gait in atypical
parkinsonism); Loris Bonetti, Ivana Maria Rosi, Rossella Guastaferro, Alessandra Cerra, Roberto
Milos, and Enrico Messina (dehydration in the elderly); Takashi Matono (relative bradycardia
in enteric fever); Mark Wright (unilateral visual loss and Marcus Gunn pupil); Alex Butskiy
(Rinne test, conductive hearing loss; orientation of tines); William Strawbridge (hearing tests);
Vincent Quagliarello (meningeal signs); Johann Steurer (pneumonia); Jason Weatherald (diagnosis of pulmonary hypertension); Gerben ter Riet (red eye); Anikar Chhabra, Keith Jarbo, DavidE.
Hartigan, Kelly Scott, and Karan Patel (tests of anterior cruciate ligament tears); and Kenneth
Arinze Ohagwu and Innocent Ijezie Chukwuonye (Siriraj Stroke scale). I greatly appreciate their
promptness in responding to my questions and their generosity in sharing data from their research.
Insights into physical signs continue to evolve and progress. is textbook presents the most
recent evidence supporting this fundamental clinical skill. By applying this evidence-based
approach, clinicians will glean the most from what they hear, see, and feel at the bedside, information that, combined with modern technological testing, will grant clinicians the keys to outstanding patient care.
Steven McGee, M.D.
February 2021
vi
CONTENTS
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PA R T
PA R T
PA R T
1
Introduction
1
What is Evidence-Based Physical Diagnosis?
2
Understanding the Evidence
2
Diagnostic Accuracy of Physical Findings
3
Using the Tables in This Book
4
Using the Online EBM Calculator
5
Reliability of Physical Findings
3
General Appearance of the Patient
6
Mental Status Examination
7
Stance and Gait
8
Jaundice
9
Cyanosis
10
Anemia
11
Hypovolemia
75
63
71
79
1
3
7
9
21
27
31
41
43
49
PA R T
12
Protein-Energy Malnutrition and Weight Loss
13
Obesity
14
Cushing Syndrome
4
Vital Signs
15
Pulse Rate and Contour
16
Abnormalities of Pulse Rhythm 109
17
Blood Pressure 119
18
Temperature 133
19
Respiratory Rate and Abnormal Breathing Patterns 143
20
Pulse Oximetry 155
85
81
89
95
97
ix
x
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Contents
PA R T
PA R T
PA R T
5
Head and Neck
191
161
215
185
269
21
The Pupils
22
Diabetic Retinopathy
23
The Red Eye
24
Hearing
25
Thyroid and Its Disorders
26
Meninges
27
Peripheral Lymphadenopathy
6
The Lungs
28
Inspection of the Chest
29
Palpation and Percussion of the Chest
30
Auscultation of the Lungs
31
Ancillary Tests
7
Selected Pulmonary Disorders
233
159
179
199
221
235
255
245
271
PA R T
32
Pneumonia
33
Chronic Obstructive Lung Disease
34
Pulmonary Embolism
35
Pleural Effusion
8
The Heart
36
Inspection of the Neck Veins
37
Percussion of the Heart
38
Palpation of the Heart
39
Auscultation of the Heart: General Principles 321
40
The First and Second Heart Sounds 325
41
The Third and Fourth Heart Sounds 335
42
Miscellaneous Heart Sounds 343
43
Heart Murmurs: General Principles 349
273
293
291
279
285
295
309
311
Contents
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xi
PART
44
45
46
47
48
49
PART
50
51
9
Selected Cardiac Disorders 367
Aortic Stenosis 369
Aortic Regurgitation 375
Miscellaneous Heart Murmurs 383
Disorders of the Pericardium 395
Congestive Heart Failure 401
Coronary Artery Disease 409
10
Abdomen 417
Inspection of the Abdomen 419
Palpation and Percussion of the Abdomen 421
52 Abdominal Pain and Tenderness 433
53
PART 11
Auscultation of the Abdomen 443
Extremities 447
54 Peripheral Vascular Disease 449
55
56
57
PART
58
59
60
61
62
63
64
65
The Diabetic Foot 457
Edema and Deep Vein Thrombosis 461
Examination of the Musculoskeletal System 467
Neurologic Examination 497
12
Visual Field Testing 499
Nerves of the Eye Muscles (III, IV, and VI): Approach to Diplopia 507
Miscellaneous Cranial Nerves 523
Examination of the Motor System: Approach to Weakness 533
Examination of the Sensory System 551
Examination of the Reexes 563
Disorders of the Nerve Roots, Plexuses, and Peripheral Nerves 575
Coordination and Cerebellar Testing 591
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