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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2853_Библиотеки_им_академика_М_И_Перельмана
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xx Contents
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6. Perception 715
7. Intellect 715
8. Mood 716
9. Affect 716
10. Appearance and Behavior 716
Psychiatric Symptoms and Signs 716
B.
1. Abnormal Perception 716
2. Parasomnias 717
3. Abnormal Affect and Mood 717
4. Abnormal Thinking 718
5. Abnormal Memory 719
6. Abnormal Behaviors 719
Psychiatric Syndromes 720
C.
1. Multiaxial Assessment 720
2. Acute and Subacute Confusion 721
3. Anxiety Disorders 721
4. Mood Disorders 722
5. Personality Disorders and Abnormal Behaviors 723
6. Eating Disorders 726
7. Alcohol-Related Illness 726
8. Impulse Control Disorders 727
9. Adjustment Disorders 727
10. Grieving 728
11. Thought Disorders 728
12. Other Disorders 728
SECTION 2
The Social Evaluation
1. Evaluating Social Function and Risk 729
A. Common Social Syndromes and Problems 729
1. Common Social Syndromes and Problems 729
B. Clinical Vignettes and Questions 731
729
PART 3
PREOPERATIVE EVALUATION
16. THE PREOPERATIVE EVALUATION 734
A. Introduction to Preoperative Screening 734
B. The History 734
1. Assessing Cardiovascular and Pulmonary
Risk from History 735
2. Assessing Bleeding Risk from History 736
3. Assessing Metabolic Risk—Diabetes, Renal, and Hepatic
Insufciency 736
4. Age 737
5. Family History 737
6. Medications 737
7. Social History 738
8. Mechanical and Positioning Risks 738
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C. The Physical Exam 738
Laboratory Testing 739
D.
E.
Summative Risk Assessment 740
Clinical Vignettes and Questions 741
F.
PART 4
USE OF THE LABORATORY AND DIAGNOSTIC IMAGING
PRINCIPLES OF DIAGNOSTIC TESTING 744
17.
A. Principles of Laboratory Testing 744
1. Principles of Testing for Disease 744
2. Selecting and Interpreting Tests 747
B. Examples 750
1. Comment 755
2. 2 × 2 Tables Revisited: Caveat Emptor 755
3. Rule-In; Rule-Out 756
4. Summary 757
C. Principles of Diagnostic Imaging 757
18. COMMON LABORATORY TESTS 759
A. Blood Chemistries 760
1. Albumin 760
2. Alkaline Phosphatase, Serum 760
3. Anion Gap, Serum 761
4. Alanine Aminotransferase (ALT), Serum 761
5. Aspartate Aminotransferase (AST), Serum 761
6. Bicarbonate, Total Serum (HCO
7. Bilirubin, Total Serum 762
-
), CO2 Content 762
3
8. Blood Urea Nitrogen (BUN) 763
9. B-Type Natriuretic Peptide 763
10. Chloride, Serum (Cl
-
) 764
11. Cholesterol, Serum 765
12. C-Reactive Protein (CRP) 765
13. Creatine Kinase (CK), Serum 766
14. Creatinine, Serum 766
15. Creatinine Clearance 767
16. Ferritin, Serum 768
17. Glomerular Filtration Rate (GFR) 768
18. Glucose, Serum 768
19. Hemoglobin A
20. Iron, Serum (Fe
, Glycohemoglobin 770
1C
2+
) 770
21. Iron-Binding Capacity, Serum Total 771
22. Lactate Dehydrogenase (LDH), Serum 771
23. Phosphate, Serum Inorganic 771
24. Potassium, Serum (K
+
) 772
25. Protein, Total Serum 773
26. Protein: Albumin, Serum 773
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27. Protein: Globulins, Serum 774
28. Protein: a
29. Protein: a
30. Protein: b-Globulins 774
31. Protein: g-Globulins 774
32. Protein: Immunoglobulin IgG 775
33. Protein: Immunoglobulin IgA 775
34. Protein: Immunoglobulin IgM 775
35. Protein: Immunoglobulin IgD 776
36. Protein: Immunoglobulin IgE 776
37. Protein: Monoclonal g-Globulins 776
38. Sodium, Serum (Na
39. Triglycerides 777
40. Urea Nitrogen 777
41. Uric Acid, Serum 777
B. Hematologic Data 778
1. Blood Cells 778
2. Erythrocyte Measurements 779
3. Leukocytes (WBC) 781
4. Coagulation 784
C. Urinalysis 784
1. Color 785
2. Acidity 785
3. Specic Gravity 785
4. Protein 785
5. Glucose 786
6. Ketones 786
7. Urine Sediment 786
8. Casts 787
D. Cerebrospinal Fluid (CSF) 787
1. Increased CSF Protein 787
2. Decreased CSF Protein 787
3. Elevated CSF Glucose 787
4. Decreased CSF Glucose 787
5. Cell Count and Differential 788
6. Increased CSF Leukocytes 788
E. Serous Body Fluids 788
1. Transudates 788
2. Exudates 788
3. Pleural Effusion 788
4. Peritoneal Effusion, Ascites 788
5. Serum/Ascites Albumin Gradient 789
6. WBC Counts 789
Appendix
790
Index 827
-Globulins 774
1
-Globulins 774
2
+
) 776
PREFACE
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To The Reader:
Pray thee, take care, that tak’st my book in hand
To read it well: that is, to understand.
The purpose of taking a clinical history and performing the physical exam
is to generate diagnostic hypotheses. This was true for Hippocrates and
Osler and remains true today. DeGowin’s Diagnostic Examination encourages a
thoughtful, systematic approach to the history, physical exam, and diagnostic
process.
The practice of medicine would be simple if each symptom or sign indicated a single disease. There are enormous numbers of symptoms and signs
(we cover several hundred) that can occur in a nearly innite number of
combinations and temporal patterns. These symptoms and signs are the raw
materials from which the clinician must weave an anatomically and pathophysiologically explicit clinical narrative forming the diagnostic hypotheses.
Mastering the diagnostic process requires:
(1) Knowledge: Familiarity with the pathophysiology, symptoms, and signs
of common and unusual diseases.
(2) Skill: The ability to take an accurate and complete history and perform
an appropriate physical examination.
(3) Experience: From longitudinal exposure to many clinical situations,
diseases, and patients, each thoroughly evaluated, the skilled clinician
becomes familiar with the presenting symptoms and signs of a wide
variety of pathophysiologic processes allowing generation of a probabilistic differential diagnosis for each patient.
(4) Judgment: Knowledge of basic medical science and the medical litera-
ture, combined with reective experience, promotes the judgment necessary to efciently test diagnostic hypotheses in the laboratory or by
clinical interventions.
—B J
DeGowin’s Diagnostic Examination has been used by students and clinicians
for over 50 years precisely because of its usefulness in honing this diagnostic
process:
(1) It describes the techniques for obtaining a complete history and perform-
ing a thorough physical exam.
(2) It links symptoms and signs with the pathophysiology of disease.
(3) It presents an approach to differential diagnosis, based upon the patho-
physiology of disease, which can be efciently tested in the laboratory.
(4) It does all of this in a format that can be used as a quick point-of-care
reference and as a text to study the principles and practice of history
taking and physical examination.
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In undertaking this eleventh edition of a venerable classic, our goal is
once again to preserve the unique strengths of previous editions, while adding recent information and references, reducing redundancy, and improving
clarity. The reason is that DeGowin’s Diagnostic Examination emphasizes the
unchanging aspects of clinical medicine—the symptoms and signs of disease
as related by the patient and discovered by physical examination. We remain
true to the original goal of this book which was to encourage a thoughtful
systematic approach to diagnosis based on history and physical examination.
In this edition at the end of chapter 4 to 16 you will also nd examples of
clinical vignettes (followed by questions) demonstrating essential concepts
used in framing diagnostic hypothesis. The answers to these questions can
be found in the Appendix. Along with the factual information stored in longterm memory, these vignettes will help facilitate development and implementation of diagnostic strategies using memory schemes that represent and
interrelate clinical problems.
Pathophysiology links the patient’s story of their illness (the history), the
physical signs of disease, and the changes in biologic structure and function
revealed by imaging studies and laboratory testing. Patients describe symptoms, we need to hear pathophysiology; we observe signs, we need to see
pathophysiology; the radiologist and laboratories report ndings, we need
to think pathophysiology. Pathophysiology and pathologic anatomy provide
the framework for understanding disease as alterations in normal physiology
and anatomy, and illness as the patient’s experience of these changes.
A discussion of
occurs after many subject headings. The discussions are brief and included
when they assist understanding the symptom or sign. Readers are encouraged to consult physiology texts to have a full understanding of normal and
abnormal physiology. In addition, each chapter discusses syndromes associated with that body region to give a sense of the common, and uncommon but
serious, disease patterns.
DeGowin’s Diagnostic Examination is organized as a useful bedside guide
to assist diagnosis. Part 1, Chapter 1 introduces the conceptual framework for
the diagnostic process, Chapter 2 the essentials of history taking and documentation, and Chapter 3 the screening physical examination with a short
introduction to bedside ultrasound. Every clinician needs a thorough understanding of Part 1 and Part 4, Chapter 17, the latter introducing the principles
of diagnostic testing.
Part 2, Chapters 4 through 15, forms the body of the book. Two introductory chapters discuss the vital signs (Chapter 4) and major physiologic
systems that do not have a primary representation in a single body region
(Chapter 5). Chapters 6 through 14 are organized around the body regions
sequentially examined during the physical examination. Each chapter has a
common structure outlined in the Introduction and User’s Guide. To avoid
duplication, the text is heavily cross-referenced. I hope the reader nds this
useful and not too cumbersome.
References to articles from the medical literature are sparingly included
in the body of the text. We have chosen articles that provide useful diagnostic information including excellent descriptions of diseases and syndromes, thoughtful discussions of the approach to differential diagnosis and
pathophysiology (highlighted in the second color)
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evaluation of common and unusual clinical problems, and, in some cases,
photographs illustrating key ndings. Most references are from the major
general medical journals, the New England Journal of Medicine, the Lancet, the
Annals of Internal Medicine, and the Journal of the American Medical Association.
This implies that a clinician who regularly studies these journals will keep
abreast of the broad eld of medical diagnosis. Some references are dated
in their recommendations for laboratory testing and treatment; they are
included because they give thorough descriptions of the relevant clinical
syndromes, often with excellent discussions of the approach to differential
diagnosis. Tests and treatments come and go, but good thinking has staying
power. The reader must always check current resources before initiating a
laboratory evaluation or therapeutic program.
Evidence-based articles on the utility of the physical examination are
included, mostly from the Rational Clinical Examination series published
in the Journal of the American Medical Association. They are included with the
caveat that they evaluate the physical examination as a hypothesis-testing
tool, not as a hypothesis generating task.
Each chapter was independently reviewed by faculty members. Their
feedback and assistance are gratefully acknowledged. Reviewers for this
edition are Bimal Ashar, MD, MBA, Division of General Internal Medicine,
Johns Hopkins University School of Medicine (Chapters 5 and 16), Karolyn
Wanat, MD, Department of Dermatology, Medical College of Wisconsin,
(Chapter 6), Doug Van Daele, MD, Department of Otolaryngology, University
of Iowa Hospitals & Clinics (Chapter 7), Karl Thomas, MD, Department of
Internal Medicine, Wake Forest School of Medicine (Chapter 8), Christopher
J. Goerdt, MD, MPH, Division of General Internal Medicine, University of
Iowa Roy J. and Lucille A. Carver College of Medicine (Chapter 9), Aash
Bhatt, MD, Department of Internal Medicine, Western Michigan University,
Homer Stryker School of Medicine (Chapter 10), Abby Hardy-Fairbanks,
MD, Department of Obstetrics and Gynecology, University of Iowa Roy J.
and Lucille A. Carver College of Medicine (Chapter 11), Chad Tracy, MD,
Department of Urology, University of Iowa Roy J. and Lucille A. Carver
College of Medicine (Chapter 12), Chadwick Johr, MD, University of
Pennsylvania Perelman School of Medicine (Chapter 13).
All editors for this edition, Manish Suneja, MD, Joseph Szot, MD, Richard
F. LeBlond and Donald D. Brown, MD, have been instrumental in seeing that
the eleventh edition maintains the strengths of previous editions while continuing to evolve to meet the reader’s needs.
Ms. Kay Conerly is the senior editor at McGraw Hill for the eleventh
edition. She has been actively involved in the planning and execution of the
eleventh edition. Her encouragement and support are deeply appreciated.
The McGraw Hill editorial and publishing staff have been prompt and professional throughout manuscript preparation, editing, and production.
The eleventh edition includes video segments demonstrating fundamental physical examination procedures. Complimentary access to these videos is available at: www.mhprofessional.com/DeGowinsDiagnosticExam.
Finally, we wish to thank our colleagues who have encouraged us
throughout the course of this project. We have incorporated many suggestions from our reviewers/readers and would like to thank those who have
xxvi Preface
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taken the time to write recommendations for this edition. Ultimately, you,
the reader, will determine the strengths and weaknesses of this edition. We
welcome your feedback and suggestions.
Manish Suneja, MD, FACP, FASN
Joseph Szot, MD, FACP
Richard F. LeBlond, MD, MACP
Donald D. Brown, MD, FACP
Iowa City, Iowa
COMMON ABBREVIATIONS
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CHF congestive heart failure
COPD chronic obstructive pulmonary disease
CLL chronic lymphocytic leukemia
CML chronic myelogenous leukemia
CMV cytomegalovirus
CN cranial nerve
CNS central nervous system
CSF cerebrospinal uid
CVP central venous pressure
DDX differential diagnosis
DIP distal interphalangeal joint
EBV Epstein–Barr virus
HIT heparin-induced thrombocytopenia
HSV herpes simplex virus
ITP idiopathic immune thrombocytopenia
LLQ left lower quadrant
LUQ left upper quadrant
LV left ventricle
MCP metacarpal–phalangeal joint
MI myocardial infarction
MS multiple sclerosis
MTP metatarsal–phalangeal joint
NBTE nonbacterial thrombotic endocarditis
PE pulmonary embolism
PIP proximal interphalangeal joint
RA rheumatoid arthritis
RLQ right lower quadrant
RUQ right upper quadrant
RV right ventricle
SBE subacute bacterial endocarditis
SLE systemic lupus erythematosus
TTP thrombotic thrombocytopenic purpura
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INTRODUCTION AND USER’S GUIDE
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Read with two objectives: rst to acquaint yourself with the current
knowledge on the subject and the steps by which it has been reached;
and secondly, and more important, read to understand and analyze your
cases.
DeGowin’s Diagnostic Examination provides the introductory knowledge base,
describes the skills, and encourages the reader to acquire the experience and
judgment needed to become a master clinical diagnostician. Despite recent
advances in testing and imaging, the clinician’s skills in taking a history and
performing a physical examination are needed now more than ever.
The history is the patient’s story of his or her illness related as the time
course of their symptoms; the physical examination reveals the signs of disordered anatomy and physiology. The symptoms and signs of disease form
temporal patterns, which the clinician recognizes from experience and knowledge of anatomy, physiology, and diseases. From the history and physical
examination, the clinician generates testable pathophysiologic and diagnostic
hypotheses—the differential diagnosis. Prociency and condence in differential diagnosis should improve with regular use of DeGowin’s Diagnostic
Examination.
The differential diagnosis is subjected to laboratory testing. Proper use
of the laboratory and imaging are based upon accurate diagnostic hypotheses
generated while taking the history and performing the physical examination.
Undisciplined use of both laboratory tests and imaging modalities is a major
cause of increasing healthcare costs and leads to further inappropriate testing and patient harm. Over-reliance on technology has contributed to loss of
clinical bedside skills.
DeGowin’s Diagnostic Examination is intended to assist the student and
clinician in making reasonable diagnostic hypotheses from the history and
physical examination. Part 1, Chapters 1 to 3, discusses the diagnostic framework in detail. Chapter 1 discusses the importance of diagnosis and the process of forming a differential diagnosis specic to each patient. Chapter 2
discusses the process of history taking and documentation of the ndings in
the medical record. Chapter 3 outlines the screening physical examination.
The heart of DeGowin’s Diagnostic Examination is Part 2, Chapters 4 thru
15. It is organized in the sequence in which the clinician traditionally performs the examination. Chapter 4 discusses the vital signs. Chapter 5 introduces some systems to keep in mind throughout the examination since they
present with symptoms and signs not easily referable to a specic body
region. Chapters 6 thru 13 discuss the diagnostic examination by body region:
the skin (Chapter 6), the head and neck (Chapter 7), the chest and breasts
(Chapter 8), the abdomen (Chapter 9), the urinary system (Chapter 10), the
female genitalia and reproductive system (Chapter 11), the male genitalia and
reproductive system (Chapter 12), the spine and extremities (Chapter 13), the
—S W O
“The Student Life”
xxix
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