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Macleod''s Clinical Diagnosis 2nd Edition 2018Macleod''s Clinical Diagnosis 2nd Edition 2018Macleod''s Clinical Diagnosis 2nd Edition 2018
https://t.me/MedicalBooksStore m eb sf sf re Macleod’s Clinical Diagnosis o This page intentionally left blank e s om m e Honorary Professor of Accident and Emergency Medicine and Surgery, University of Edinburgh UK ok o oo Colin Robertson BA(Hons) MBChB FRCPGlas FRCSEd FICP(Hon) FSAScot eb ks ee om co m Consultant Cardiologist, Royal Infirmary of Edinburgh; Honorary Clinical Senior Lecturer, University of Edinburgh UK m eb Alan G Japp MBChB(Hons) BSc(Hons) MRCP PhD Clinical Diagnosis 2nd Edition ks f ks fre ks fre e c Macleod’s Co-authors e Rohana J Wright fre MBChB MD FRCPEd ks Consultant Physician, St John’s Hospital, oo o Livingston, and Edinburgh Centre for Endocrinology and Diabetes, Edinburgh, UK Matthew J Reed MA(Cantab) MB BChir MRCS FCEM MD Consultant and NRS Career Researcher Clinician in Emergency Medicine, Honorary Reader, o Royal Infirmary of Edinburgh; UK e University of Ed nburgh ks Andrew Robson oo MA (Cantab) BM BCh FRCS PhD Specialist Registrar in General Surgery, Royal Infirmary of Edinburgh, UK Edinburgh London New York Oxford Philadelphia St Louis Sydney 2018 ks fre © 2018 Elsevie Ltd All rights reserved bo oo ok sf r No part of this publication may be reproduced or transmitted in any form or by any means, elec ronic or mechanical, including photocopying recording, or any information storage and retrieval system, without permission in writing f om 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 2013 Second edition 2018 c ISBN 9780702069611 International ISBN 9780702069628 bo oo ok ks sf re fre 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 re e The publisher s pol cy is to use paper manufactured from sustainable forests Content Strategist: Laurence Hunter Content Development Specialist: Helen Leng Project Manager: Louisa Talbott Designer: Miles Hitchen Illustration Manager: Karen Giacomucci Illustrator: Antbits o Printed in Poland Last digit is the print number 9 8 7 6 5 4 3 2 1 m e Contents om Preface vii Acknowledgements viii Abbreviations ix fr PRINCIPLES OF CLINICAL ASSESSMENT Assessing patients: a practical guide 17 22 Abdominal pain 24 Breast lump 46 Chest pain 50 Coma and altered consciousness 72 Confusion: delirium and dementia 78 Diarrhoea 90 o sf co ASSESSMENT OF COMMON PRESENTING PROBLEMS m The diagnostic process 10 Dizziness 96 11 Dysphagia 108 12 Dyspnoea 112 m 13 Fatigue 130 14 Fever 138 15 Gastrointestinal haemorrhage: haematemesis and rectal bleeding 150 17 Haemoptysis 158 162 k 16 Haematuria ee SECTION 1 What’s in a diagnosis? eb fr SECTION 18 Headache 166 19 Jaundice 174 vi • CONTENTS 184 21 Leg swelling 190 196 23 Low back pain 208 24 Mobility problems: falls and immobility 214 25 Nausea and vomiting 222 26 Palpitation 232 27 Rash: acute generalized skin eruption 240 28 Red eye 250 29 Scrotal swelling 258 30 Shock 264 s m 22 Limb weakness om s e 20 Joint swelling 270 32 Urinary incontinence 282 33 Vaginal bleeding 288 34 Weight loss 294 m b o 31 Transient loss of consciousness: syncope and seizures om Appendix 301 Index 305 m Preface oo eb m m co co f oo eb bo o sf re e e fe ks oo sf re e c sf m m eb o oo s r These, or similar platitudes, will be familiar to most students in clinical training Many, however, notice a ‘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 recognize that teachers and textbooks frequently fall into the trap of eulogizing 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 In many ‘developed’ countries, some so-called classical physica signs are rare and certain aspects of the clinical examination have been marginalized by novel imaging techniques and disease biomarkers Nevertheless, a focused clinical examination is critical to recognizing the sick patient, raising red flags identifying unsuspected problems and, in some cases, revealing signs that cannot be identified 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 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 Alan Japp Colin Robertson Edinburgh, 2018 om m ‘Ninety per cent of diagnoses are made from the history.’ ‘Clinical examination is the cornerstone of assessment.’ m Acknowledgements f ks sf re e c om Edinburgh (Chapter 28, Red eye); Dr Lydia Ash, Specialty Registrar, Obstetrics & Gynaecology, Edinburgh (Chapter 33, Vaginal bleeding), Mr Andrew Duckworth, Specialty Registrar, Orthopaedic Surgery, Edinburgh (Chapter 20, Joint swelling) and Mr Neil Maitra, Locum Consultant Urologist, Lanarkshire (Chapter 16, Haematuria) and everyone else who has volunteered ideas, comments, assistance or a friendly ear AJ oo o eb bo ok s re e c om On behalf of the editors and authors, I would like to thank Laurence Hunter for encouraging and facilitating this new edition; and Helen Leng for once again providing the perfect blend of tolerance, support and discipline We also thank everyone who volunteered suggestions and ideas for the 2nd edition, particularly Dr Vicky Tallen ire, Dr Michael MacMahon and Dr Dean Kerslake Finally we gratefully acknowledge a valuable contribution to individual chapters from Dr Mark Wright, Consultant Ophthalmologist, m e Abbreviations c fr sf m o re e .c co om m o ok sf fre e co co m m m eb oo re e c om om Abbreviations that not appear in this list are spelled out in the main text DMARD disease-modifying anti-rheumatic ABCDE airway, breathing, circulation, drug disability exposure ECG electrocardiogram/ ABG arterial blood gas electrocardiography ACE angiotensin-converting enzyme EEG electroencephalogram/ ACPA anti-citrullinated protein antibody electroencephalography ACTH adrenocorticotrophic hormone ENA extractable nuclear antigen AIDS acquired immunodeficiency ENT ear, nose and throat syndrome ERCP endoscopic retrograde ALP alkaline phosphatase cholangiopancreatography ALT alanine aminotransferase ESR erythrocyte sedimentation rate ANA antinuclear antibody FBC full blood count ANCA antineutrophil cytoplasmic antibody FiO2 APTT activated partial thromboplastin fraction of inspired oxygen time GCS Glasgow Coma Scale (score) ASMA anti-smooth muscle antibody GFR glomerular filtration rate ASO anti-streptolysin O GGT gamma-glutamyl transferase AST aspartate aminotransferase GI gastrointestinal AXR abdominal X-ray GP general practitioner BMI body mass index GU genitourinary BP blood pressure Hb haemoglobin bpm beats per minute hCG human chorionic gonadotrophin BS breath sound HIV human immunodeficiency virus CBG capillary blood glucose HR heart rate CLO campylobacter-like organism ICP intracranial pressure CK creatine kinase ICU intensive care unit CKD chronic kidney disease ID infectious disease CNS central nervous system IM intramuscular(ly) COPD chronic obstructive pulmonary INR international normalized ratio disease IV intravenous(ly) CPET cardiopulmonary exercise test IVU intravenous urogram/urography CRP C-reactive protein JVP jugular venous pulse CRT capillary refill time LDH lactate dehydrogenase CSF cerebrospinal fluid LFT liver function test CSU catheter specimen of urine LIF left iliac fossa CT computed tomogram/tomography LKM liver kidney microsomal CTPA computed tomographic pulmonary (antibodies) angiography LLQ left lower quadrant CVP central venous pressure LP lumbar puncture CXR chest X-ray LUQ left upper quadrant DC direct current MRA magnetic resonance angiography 302 • APPENDIX + Non-SI units 21–29 mmol/L 21–29 meq/L o Bicarbonate (HCO3) Reference range SI units bo oo Analysis ok s fr Arterial blood analysis Hydrogen ion (H ) 37–45 nmol/L PaCO2 4.5–6.0 kPa pH 7.35–7.43 34–45 mmHg PaO2 12–15 kPa 90–113 mmHg Oxygen saturation (SpO2) >97% 1,2 Breathing room air Varies with age k Haematological values Non-SI units Bleeding time (Ivy)