Contents

Cover

Title Page

Copyright

Preface to the Seventh Edition

Acknowledgements

Preface to the First Edition

Part 1: Clinical Examination

Chapter 1: The Medical Interview

Effective Consultation

Special Circumstances

Assessment of Communication Skills

Reference

Chapter 2: General Examination

Introduction

Hands

Face

Neck

Axillae

Breasts (Fig. 2.1)

Legs

Notes

Chapter 3: Cardiovascular System

Introduction

General Inspection

Blood Pressure

Hands

Arterial Pulses

Jugular Venous Pressure and Pulse (Table 3.2; Fig. 3.1)

Heart

Complete the Examination

Notes

Chapter 4: Respiratory System

History

Examination

Notes

Investigation of the Respiratory System

Blood Gases

Interpretation of Blood Gases

Pulmonary Function Tests

Chapter 5: The Abdomen

Examination of the Abdomen

Notes

Palpable Kidneys

Mass in Right Subcostal Region

Suprapubic Mass

Ascites

Dysphagia

Diarrhoea

Jaundice

Congenital Non-haemolytic Hyperbilirubinaemias

Renal Disease

Chapter 6: Neurological System

History

Examination of the Nervous System

Mental State and Higher Cerebral Function

Speech Disorders

Cranial Nerves

Hearing and Vestibular Function (8th Nerve)

The Limbs

Notes

Patterns of Motor Loss in the Limbs

Patterns of Sensory Loss in the Limbs

Abnormalities of Coordination

Abnormal Gait

Tremors

Chapter 7: Endocrinology and Metabolism

History

Examination

Hands

Arterial Pulse

Blood Pressure

Skin

Face

Eyes

Neck

Breasts

External Genitalia

Legs

Notes

Chapter 8: Musculoskeletal System

History

Examination

Notes

Chapter 9: Assessment

Standard Setting

Assessment of Clinical Competence

Part 2: Clinical Medicine

Chapter 10: Cardiovascular Disease

Ischaemic Heart Disease

Myocardial Infarction

Arrhythmias

Cardiorespiratory Arrest

Cardiovascular Disorders and Driving

Heart Failure

Ventricular Arrythmias and Sudden Death

Hypertension

Severe Hypertension

Hypertension in Relation to Other Conditions

Valvular Heart Disease

Congenital Heart Disease

Atrial Septal Defect (ASD)

Patent Ductus Arteriosus

Ventricular Septal Defect

Fallot's Tetralogy

Coarctation of the Aorta

Eisenmenger Syndrome

Infective Endocarditis

Constrictive Pericarditis

Acute Pericarditis

Syphilitic Aortitis and Carditis

Cardiomyopathy

Hypertrophic Cardiomyopathy

Dilated (Congestive) Cardiomyopathy

Restrictive Cardiomyopathy

Peripheral Arterial Disease

Intermittent Claudication

Acute Obstruction

Ischaemic Foot

Raynaud's Phenomenon

Reference

Chapter 11: Respiratory Disease

Chronic Obstructive Pulmonary Disease (COPD)

Asthma

Respiratory Failure

Acute on Chronic Respiratory Failure

Acute Anaphylaxis

Pneumonia

Lung Abscess

Bronchiectasis

Pneumothorax

Cystic Fibrosis

Lung Cancer

Bronchial Adenoma

Sarcoidosis

Tuberculosis

Occupational Lung Diseases

Obstructive Sleep Apnoea

Pulmonary Embolism

Hyperventilation Syndrome

Fibrosing Alveolitis

Adult Respiratory Distress Syndrome

Chapter 12: Gastroenterology

Gastric and Duodenal Ulceration

Gastric Carcinoma

Hiatus Hernia and Gastro-Oesophageal Reflux

Inflammatory Bowel Disease (Ulcerative Colitis and Crohn's disease)

Extraintestinal Manifestations of Inflammatory Bowel Disease

Intestinal Cancer in Inflammatory Bowel Disease

Endocrine Tumours of the Gut

Endocrine Tumours of the Pancreas

Gastrointestinal Haemorrhage

Steatorrhoea and Malabsorption

Diverticular Disease

Irritable Bowel Syndrome

Ischaemic Colitis

Pancreas

Gall Bladder

Chapter 13: Liver Disease

Acute Hepatitis

Viral Hepatitis

Autoimmune Hepatitis

Alcoholic Hepatitis

Chronic Liver Disease

Chronic Hepatitis

Cirrhosis

Hepatocellular Failure

Portal Hypertension

Budd–Chiari syndrome

Rare Cirrhoses

Drug Jaundice

Chapter 14: Renal Disease

Urinary Tract Infection

Stones

Chronic Interstitial Nephritis

Reflux Nephropathy

Proteinuria

Nephrotic Syndrome

Haematuria

Acute Kidney Injury

Chronic Kidney Disease

Glomerulonephritis

IgA-Nephropathy

Henoch-Schönlein purpura

Membranous Nephropathy

Membranoproliferative (Mesangiocapillary) Glomerulonephritis

Minimal-Change Nephropathy

Focal Glomerulosclerosis

Systemic Vasculitis

Renal Lesion

Antiglomerular Basement Membrane Disease (Goodpasture's disease)

Systemic Lupus Erythematosus

Post-Streptococcal Glomerulonephritis

Fluid and Electrolytes

Metabolic Acidosis

Metabolic Alkalosis

Hypercalcaemia

Hypocalcaemia

Hypomagnesaemia

Hyperphosphataemia

Hypophosphataemia

Uric Acid

Chapter 15: Neurology

Headache

Primary Headache Syndromes

Secondary Causes of Headache

Neuralgias

Epilepsy

Stroke

Venous Infarction

Transient Ischaemic Attack (TIA)

Extracerebral Haemorrhage

Dementia

Multiple Sclerosis

Motor Neurone Disease

Parkinson's Disease and Other Extrapyramidal Disorders

Disorders of the Spinal Cord (Table 15.6)

Peripheral Nerve Disorders

Disorders of the Neuromuscular Junction

Disorders of Muscles

Neurological Infections

Miscellaneous Neurological Disorders

Head Injury and the Glasgow Coma Scale

Chapter 16: Endocrine Disorders

Thyroid

Pituitary

Adrenal

Chapter 17: Metabolic Disorders

Diabetes Mellitus

Diabetic Emergencies

Long-Term Diabetic Complications

Other Complications

Diabetes and Pregnancy

Other Important Information for Patients with Diabetes

Dyslipidaemia

Obesity

Under(mal)nutrition

Vitamin Deficiencies

Enteral Feeding

Parenteral Nutrition

Anorexia Nervosa

Porphyria

Metabolic Bone Disease

Hypercalcaemia

Hyperparathyroidism

Hypocalcaemia

Hypoparathyroidism

Chapter 18: Rheumatology

Osteoarthritis (OA)

Rheumatoid Arthritis (RA)

Seronegative Spondyloarthropathies

Autoimmune Rheumatic Disorders (Connective Tissue Diseases)

Inflammatory Myopathies

Vasculitides

Large-Vessel Vasculitis

Takayasu’s Arteritis (’Pulseless Disease’)

Medium-Sized Vessel Vasculitis

Small-Vessel Vasculitis

Crystal Arthropathies

Miscellaneous Rheumatological Disorders

Chapter 19: Dermatology

Psoriasis

Eczema/Dermatitis

Acne Vulgaris

Rosacea

Hidradenitis Suppurativa

Bacterial, Viral, Fungal and Parasitic Skin Infections

Cutaneous Drug Reactions

Skin Manifestations of Systemic Disease

Bullous Disorders

Benign and Malignant Skin Tumours

Miscellaneous Skin Conditions

Disorders of the Hair and Nails

Chapter 20: Haematology

Peripheral Blood Film Features (Fig. 20.1)

Reticulocytes

Normocytic Anaemia

Microcytic Anaemia

Macrocytic Anaemia

Anaemia Secondary to Chronic Disease

Pancytopenia

Marrow Suppression

Erythrocyte Sedimentation Rate (ESR)

Anaemia

Haemolytic Anaemia (Table 20.3)

Bleeding Disorders

Leukaemia

Lymphoma

Myeloma

Amyloidosis

Chapter 21: Infectious Diseases

Imported Diseases

Septicaemia

Influenza

Human Immunodeficiency Virus Infection

Infectious Mononucleosis (Glandular Fever)

Tuberculosis

Chronic Fatigue Syndrome

Chapter 22: Toxicology

Clinical Presentation

Management

Carbon Monoxide Poisoning

SI Units conversion table

Color plates

Index

This edition first published 2012, © 2012 by John Bradley, Mark Gurnell, Diana Wood, David Rubenstein and David Wayne

Previous editions: 1976, 1980, 1985, 1991, 1997, 2003

Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell's publishing programme has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell.

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Library of Congress Cataloging-in-Publication Data

Bradley, John, MRCP.

Lecture notes. Clinical medicine / John Bradley, Mark Gurnell, Diana Wood. -

- 7th ed.

p. ; cm.

Clinical medicine

Rev. ed. of: Lecture notes on clinical medicine / David Rubenstein, David Wayne, John Bradley. 6th ed. 2003.

Includes index.

ISBN 978-1-4051-5714-8 (pbk. : alk. paper)

I. Gurnell, M. II. Wood, Diana. III. Rubenstein, David. Lecture notes on clinical medicine. IV. Title. V. Title: Clinical medicine.

[DNLM: 1. Clinical Medicine–Handbooks. WB 39]

616–dc23

2011042644

A catalogue record for this book is available from the British Library.

Cover image: Dana Neely/Corbis

Cover design: Grounded Design

Preface to the Seventh Edition

History-taking and examination remain the essential tools of clinical medicine. However, the environment in which medicine is practised has changed since the first edition of Lecture Notes in Clinical Medicine in 1975. The seventh edition follows the format of previous editions of this book with two sections: Clinical Examination and Clinical Medicine. Each section has been updated to reflect the increased evidence upon which clinical practice is based and the more objective methods of assessment that are now used.

It is rewarding to discover how many readers have found the text useful for study, for revision and for the practice of clinical medicine. Please continue to let us have your views.

John Bradley
Mark Gurnell
Diana Wood

Acknowledgements

We would like to thank Dr Ellie Gurnell, Dr Mark Lillicrap and Dr Narayanan Kandasamy for their contributions, help and advice during the preparation of the manuscript.

Preface to the First Edition

This book is intended primarily for the junior hospital doctor in the period between qualification and the examination for Membership of the Royal Colleges of Physicians. We think that it will also be helpful to final-year medical students and to clinicians reading for higher specialist qualifications in surgery and anaesthetics.

The hospital doctor must not only acquire a large amount of factual information but also use it effectively in the clinical situation. The experienced physician has acquired some clinical perspective through practice: we hope that this book imparts some of this to the relatively inexperienced. The format and contents are designed for the examination candidate but the same approach to problems should help the hospital doctor in his everyday work.

The book as a whole is not suitable as a first reader for the undergraduate because it assumes much basic knowledge and considerable detailed information has had to be omitted. It is not intended to be a complete textbook of medicine and the information it contains must be supplemented by further reading. The contents are intended only as lecture notes and the margins of the pages are intentionally large so that the reader may easily add additional material of his own.

The book is divided into two parts: the clinical approach and essential background information. In the first part we have considered the situation which a candidate meets in the clinical part of an examination or a physician in the clinic. This part of the book thus resembles a manual on techniques of physical examination, though it is more specifically intended to help the candidate carry out an examiner's request to perform a specific examination. It has been our experience in listening to candidates’ performances in examinations and hearing the examiner's subsequent assessment that it is the failure of a candidate to examine cases systematically and his failure to behave as if he were used to doing this every day of his clinical life that leads to adverse comments.

In the second part of the book a summary of basic clinical facts is given in the conventional way. We have included most common diseases but not all, and we have tried to emphasise points which are understressed in many textbooks. Accounts are given of many conditions which are relatively rare. It is necessary for the clinician to know about these and to be on the lookout for them both in the clinic and in examinations. Supplementary reading is essential to understand their basic pathology, but the information we give is probably all that need be remembered by the non-specialist reader and will provide adequate working knowledge in a clinical situation. It should not be forgotten that some rare diseases are of great importance in practice because they are treatable or preventable, e.g. infective endocarditis, hepatolenticular degeneration, attacks of acute porphyria. Some conditions are important to examination candidates because patients are ambulant and appear commonly in examinations, e.g. neurosyphilis, syringomyelia, atrial and ventricular septal defects.

We have not attempted to cover the whole of medicine, but by cross-referencing between the two sections of the book and giving information in summary form we have completely omitted few subjects. Some highly specialised fields such as the treatment of leukaemia were thought unsuitable for inclusion.

A short account of psychiatry is given in the section on neurology since many patients with mental illness attend general clinics and it is hoped that readers may be warned of gaps in their knowledge of this important field. The section on dermatology is incomplete but should serve for quick revision of common skin disorders.

Wherever possible we have tried to indicate the relative frequency with which various conditions are likely to be seen in hospital practice in this country and have selected those clinical features which in our view are most commonly seen and where possible have listed them in order of importance. The frequency with which a disease is encountered by any individual physician will depend upon its prevalence in the district from which his cases are drawn and also on his known special interests. Nevertheless, rare conditions are rarely seen; at least in the clinic. Examinations, however, are a ‘special case’.

We have used many generally accepted abbreviations, e.g. ECG, ESR, and have included them in the index instead of supplying a glossary.

Despite our best efforts, some errors of fact may have been included. As with every book and authority, question and check everything – and please write to us if you wish.

We should like to thank all those who helped us with producing this book and, in particular, Sir Edward Wayne and Sir Graham Bull who have kindly allowed us to benefit from their extensive experience both in medicine and in examining for the Colleges of Physicians.

David Rubenstein
David Wayne
November 1975

Part 1

Clinical Examination

Chapter 1

The Medical Interview

Good communication between doctor and patient forms the basis for excellent patient care and the clinical consultation lies at the heart of medical practice. Good communication skills encompass more than the personality traits of individual doctors – they form an essential core competence for medical practitioners. In essence, good communication skills produce more effective consultations and, together with medical knowledge and physical examination skills, lead to better diagnostic reasoning and therapeutic intervention. The term ‘communication skills’, when applied to medical practice, describes a set of specific skills that can be taught, learned and assessed. A large evidence-base shows that health outcomes for patients and both patient and doctor satisfaction within the therapeutic relationship are enhanced by good communication skills.

In this chapter the medical interview as a whole will be considered and then the way in which communication skills should be approached in different types of assessment encountered by students and trainees reviewed.

There are a number of different models for learning communication skills in use throughout the world. They are generally similar and all emphasise the importance of patient-centred interview methods. This chapter is based on the Calgary–Cambridge model (Fig. 1.1) which has been widely adopted in Europe and the USA and with which the authors are familiar as a means of teaching and learning and as a framework for assessment (Silverman et al. 2005). Like all clinical skills, communication skills can only be acquired by experiential learning. This may take the form of small group learning with role play, the use of actors in simulated learning environments or, for more experienced learners, in recorded real consultations with subsequent feedback.

Figure 1.1 The Calgary–Cambridge Guide. From Kurtz, S., et al. (2005) Teaching and Learning Communication Skills in Medicine, 2nd edn. Radcliffe Publishing, Oxford.

Effective Consultation

Effective consultations are patient-centred and efficient, taking place within the time and other practical constraints that exist in everyday medical practice. The use of specific communication skills together with a structured approach to the medical interview can enhance this process. Important communication skills can be considered in three categories: content, process and perceptual skills (see Table 1.1); these mirror the essential knowledge, skills and attitudes required for good medical practice. These skills are closely interrelated so that, for example, effective use of process skills can improve the accuracy of information gathered from the patient, thus enhancing the content skills used subsequently in the consultation.

Table 1.1 Categories of communication skills

Skill | Examples
Content skills |
What the doctor communicates | Knowledge-based: appropriate questions and responses; accurate information gathering and explanation to patient; clear discussion of investigation and treatments based on knowledge
Process skills |
How the doctor communicates | Skills-based: verbal and non-verbal communication skills; relationship building; organising and structuring the interview
Perceptual skills |
What the doctor is thinking | Attitude-based: clinical reasoning and problem-solving skills; attitudes towards the patient; feelings and thoughts about the patient; awareness of internal biases

Structure

Providing structure to the consultation is one of the most important features of effective consultation. Process skills should be used to develop a structure that is responsive to the patient and flexible for different consultations. Six groups of skills can be identified and each will be considered below.

Sequential in the consultation:

initiating the session

gathering information (including from physical examination)

explanation and planning

closing the session

Throughout the consultation:

organisation

relationship building

Initiating the Session

The initial part of a consultation is essential to form the basis for relationship building and to set objectives for the rest of the interview. Before meeting a patient, the doctor should prepare by focusing him- or herself, trying to avoid distractions and reviewing any available information such as previous notes or referral letters.

Initiating the Session

Establish rapport: greet the patient, confirm their name, introduce yourself and explain your role, attend to the patient's comfort.

Identify the reason for the consultation: use an appropriate opening question, listen to the patient, confirm the problem and screen for any other issues that the patient may wish to discuss.

Confirm an agenda for the consultation.

Physical Examination

Ask permission: gain the patient's consent for examination.

Ensure that the patient is comfortable: position them adequately for the examination; if doing a full examination, cover parts of the body not being examined actively.

Be clear and precise: explain what you are going to do in advance.

Be aware: the patient may be embarrassed or in pain.

Gathering Information

An accurate clinical history provides about 80% of the information required to make a diagnosis. Traditionally, history-taking focused on questions related to the biomedical aspects of the patient's problems. Recent evidence suggests that better outcomes are obtained by including the patient's perspective of their illness and by taking this into account in subsequent parts of the consultation. The objectives for gathering information should therefore include exploring the history from both the biomedical and patient perspectives, checking that the information gathered is complete and ensuring that the patient feels that the doctor is listening to them.

Gathering Information

Ask the patient to tell their own story.

Listen attentively: do not interrupt; leave the patient time and space to think about what they are saying.

Use open and closed questions: clarify issues in the history; use clear, concise and easily understood questions; move from open to closed questions then back again.

Use verbal and non-verbal facilitation: silences, repetition, paraphrasing.

Pick up on patient's verbal and non-verbal clues: acknowledge them by checking.

Summarise at intervals: verify your understanding; allow the patient to correct or add to the history.

Encourage the patient to express their feelings: actively seek their ideas, concerns and expectations.

Further information is gathered from the physical examination. Establishment of a good rapport during the first part of the consultation will facilitate communication during the examination. An appropriate chaperone should be present during the physical examination.

Explanation and Planning

Explanation and planning is crucially important to the effective consultation. Establishment of a management plan jointly between the doctor and the patient has important positive effects on patient recall, understanding of their condition, adherence to treatment and overall satisfaction. Patient expectations have changed and many wish to be more involved in decision-making about investigation and treatment options. The goals of this part of the consultation are thus to gauge the amount and type of information required by each individual patient, to provide information in a way that the patient can remember and understand and which takes their perspectives into account, to arrive at a shared understanding of the problem and to engage the patient in planning the next moves.

Explanation and Planning

Avoid jargon: use clear concise language; explain any medical terminology.

Find out what the patient knows: establish prior knowledge; find out how much they wish to know at this stage.

‘Chunk and check’: provide information in small amounts and check understanding; use this to assess how to proceed.

Organise explanation: develop a logical sequence; categorise information; repeat and summarise; signpost what is coming next; use diagrams or charts, written information or instructions.

Relate the information to the patient's perspective.

Respond to patient's cues: verbal and non-verbal; allow patient to ask questions or clarify information.

Involve the patient: share thoughts; reveal rationale for opinions; offer your opinion of what is going on and name it where possible; explore management options; take the patient's lifestyle and cultural background into account in the discussion.

Negotiate a mutually agreeable action plan: check that this meets the patient's expectations and addresses their concerns.

Closing the Session

Closing the interview allows the doctor to summarise and clarify the plans that have been made and what the next steps will be. It is also important to ensure that contingency plans are in place in case of unexpected events and that the patient is clear about follow-up arrangements. Continuing to foster the doctor–patient relationship in this way has positive effects on adherence to treatment and health outcomes.

Closing the Session

Summarise: review the consultation and clarify the plan of action; make a contract with the patient about the next steps.

Describe contingency plans: explain any possible unexpected outcomes; how and when to seek help.

Final check: ensure that the patient agrees and has no further questions.

Two essential parts of effective consultation skills run throughout the interview – organisation and relationship building. The way in which these two are used is shown in Table 1.2.

Table 1.2 Skills for organising the consultation and building the relationship

Organisation allows a flexible but ordered and logical process to occur within an appropriate time-frame. It encourages patient participation and collaboration and facilitates accurate information gathering.

Building a relationship with the patient involves a number of communication skills that enable the doctor to establish rapport and trust between themselves and the patient. It maximises the chances of accurate information gathering, explanation and planning and can form part of the development of a continuing relationship over time. It is vital to patient and doctor satisfaction with the consultation process.

Special Circumstances

Certain circumstances demand a special approach to communication skills, such as breaking bad news, dealing with cultural diversity, using an interpreter, and consultation with the elderly, with mentally ill patients or the parents of a sick child. In essence, the core communication skills described here form the basis for any of the more difficult communication skills scenarios. Complex situations require the doctor to use basic skills to a higher level. Preparation and planning, listening to the patient, delivering information in small amounts with regular checking and allowing time for information to be assimilated and for questioning are paramount. Closure is also important, ensuring the patient knows what is happening and is clear about the next steps.

Breaking Bad News

Prepare: ensure you have all the clinical details and know the facts; set aside enough time; encourage the patient to bring a relative or friend.

Start the session: review what has happened so far; assess the patient's state of mind; find out what they know and what they are thinking.

Share the information: warn the patient that the news is not good; give the information clearly and in small amounts; relate to the patient's perspective; do not overwhelm with information in the first instance; check repeatedly that the patient understands.

Be sensitive: respond to the patient's emotions – tears, anger, denial; allow time for silences and questions and respond to them honestly; gauge the patient's wishes for information and respond accordingly; be empathic and concerned; check the patient's understanding of what you have said and elicit their concerns and understanding of the situation; do not be afraid to show your own emotions.

Make a plan: explain what will happen next; give hope but be realistic; confirm your role as a partner in care.

Closure: summarise and check the patient's understanding; respond to additional questions; check the patient's support systems and offer to speak to family if requested; make an early follow-up appointment.

Assessment of Communication Skills

Clinical competence is assessed at all levels of medical education. Communication skills are usually assessed in undergraduate examinations by stations in Objective Structured Clinical Examinations (OSCEs). More varied assessments take place for postgraduates, including stations in the Royal College of Physicians MRCP Part 3 examination (Practical Assessment of Clinical Examination Skills; PACES) and mini-CEX assessments as part of ongoing workplace-based assessments for trainees. Students and trainees attempting these assessments should have been through appropriate communication skills experiential learning programmes allowing them to develop skills in simulated environments and practise them in clinical settings (Fig. 1.2). Whatever the assessment format, a number of factors should be addressed.

Approach to Communication Skills Assessment

Past papers: the format of the examination should be available for review; look at the communication skills stations; familiarise yourself with the format; are the process and content components weighted and, if so, how?

Be prepared: obtain as much information as possible in advance of the assessment; how long are the stations? Is the station simply an observed communication scenario or is a structured viva involved? In some examinations the clinical scenario is available in advance of the examination to allow preparation of content – if so, read it carefully and be certain of the medical facts.

Read the instructions: in most summative assessments the scenario is presented at the station with a few minutes' reading time. Read the scenario carefully. Think about the content as well as the process skills.

Be clear about the task: are you required to take a history, to give information, gain consent for a procedure, talk to a relative or colleague?

Make a plan: before you enter the station, have a clear plan as to how you will approach the consultation and what you wish to achieve.

Think about what you might encounter: communication skills assessments usually use simulated patients who may respond in a number of ways. For example, how will you deal with an emotional patient, a non-communicative patient or an angry response to breaking bad news?

Listen to the examiner: if you are asked to present and discuss the case, listen carefully to the examiner and present the salient features in a clear and logical manner.

Figure 1.2 Application of the Experiential Learning Cycle to learning communication skills. The learning process may begin with any of the four types of experience. The cycle enables the learner to build on existing knowledge and skills, to take responsibility for their own progress and to use real life clinical and simulated encounters to promote further learning.

(From Kolb's experiential learning theory: Kolb, D.A. 1984 Experiential Learning: experience as the source of learning and development. Prentice Hall, Englewood Cliffs, NJ).

Reference

Silverman, J., Kurtz, S. and Draper, J.(2005) Skills for Communicating with Patients, 2nd edition. Oxford: Radcliffe Publishing.

Chapter 2

General Examination

Introduction

General examination can reveal abnormalities in a number of systems which may assist in making an accurate diagnosis.

Disorders of gait, speech and mood should be apparent on first meeting the patient and during the consultation process. Dyspnoea may be observed and abnormal movements, including tremor or paucity of facial expression, should be noted.

During the general examination, obvious features of systemic disease in one site should be correlated with signs elsewhere.

Hands

Note

joint disorders – arthritis, gout, deformity

neuromuscular changes – muscle wasting, loss of function

skin temperature

warm, cyanosed hands with bounding pulse in CO₂ retention

cold pale hands with arterial disease

fingers

Raynaud's phenomenon, other signs of systemic sclerosis

nicotine staining

Osler's nodes (endocarditis, vasculitis)

nails

anaemia (pallor, koilonychia)

peripheral cyanosis

splinter haemorrhages

clubbing – swelling of the ends of the fingers with increased curvature of the nails and loss of the angle at the nail beds

palmar erythema

Dupuytren's contracture

tremor

fine tremor may be exaggerated by placing a piece of paper over the patient's outstretched hands

outstretched hands exaggerate the coarse tremor of CO₂ retention

flapping tremor in hepatic failure, uraemia – ask the patient to cock their wrists with the hands outstretched

resting tremor of Parkinson's disease – hands flexed and showing coarse ‘pill-rolling’ tremor relieved by intention

intention tremor – benign or cerebellar

Face

Check for

anaemia: examine the insides of the eyelids, look for glossitis (pernicious anaemia) and angular cheilitis

dental hygiene, tonsillar enlargement, buccal pigmentation inside the mouth

Cardiorespiratory system

cyanosis: examine the underside of the tongue

observe pursing of the lips on expiration in obstructive airways disease

lupus pernio indicates sarcoidosis

Gastrointestinal system

jaundice – examine the sclera

spider naevi

Peutz–Jeghers syndrome

hereditary haemorrhagic telangiectasia

Neurological system

Upper motor neuron (UMN) or lower motor neuron (LMN) facial palsy: differentiate stroke from Bell's palsy; examine the external auditory meatus for evidence of herpes zoster

ptosis and oculomotor palsies

Parkinsonism

myopathy: cataract and frontal baldness suggest dystrophia myotonica

ophthalmic herpes zoster including the conjunctiva

Endocrine system

Observe typical features of

thyrotoxicosis: including thyroid eye disease in Grave's disease

hypothyroidism

Cushing syndrome

acromegaly

Paget's disease involving the skull

Auto-immune diseases

systemic lupus erythematosus – photosensitive ‘butterfly rash’

scleroderma – microstomia, tightening of the skin

dermatomyositis – ‘heliotrope’ periorbital rash

Skin diseases

acne vulgaris

acne rosacea

psoriasis: check behind the ears

port wine stain

Rheumatological system

gouty tophi – check the pinnae

Neck

Examine

the jugular venous pressure (JVP)

the thyroid gland

cervical lymph nodes including the occipital group

Axillae

With shoulders relaxed examine

anterior, posterior and lateral walls and apices of axillae for lymphadenopathy

Breasts (Fig. 2.1)

Examine systematically in women and men where indicated

nipples

four quadrants of each breast

axillary tails of each breast

axillae

Figure 2.1 Breast examination. (a) Inspection. (b) Palpation. (c) Non-dominant hand stretching the skin. (d) Examination of the axilla.

Legs

Cardiorespiratory system

pitting oedema – note the extent of peripheral oedema

evidence of peripheral vascular disease – absent foot pulses, delayed capillary filling, ulceration, gangrene

varicose veins – note and examine formally if present

ulceration – note whether venous or arterial

assess the temperature of the dorsum of each foot, noting asymmetry, interdigital infection and loss of hair

palpate the dorsalis pedis and posterior tibial pulses

palpate the popliteal and femoral pulses

auscultate for bruits over femoral pulses

Rheumatological system

obvious joint deformity consistent with specific arthritides including gout

bone deformity – Paget's disease in the tibiae

Neurological system

Charcot joints

peripheral neuropathy

effects of chronic neurological lesions – UMN (stroke), multiple sclerosis, polio

subacute combined degeneration of the cord; hereditary ataxias

Skin

cellulitis

varicose eczema with haemosiderosis

psoriasis

specific skin lesions – erythema nodosum

Endocrine system

pretibial myxoedema

pyoderma gangrenosum

Notes

Lymphadenopathy

A systematic approach to the detection of lymphadenopathy is required. Examine all the major lymph nodes in a logical order:

cervical

supraclavicular

axillary

inguinal.

If lymphadenopathy is detected, examine the abdomen for hepatosplenomegaly.

Chapter 3

Cardiovascular System

Introduction

Diagnostic accuracy when assessing patients with cardiovascular disease relies heavily on the medical history. Many patients with ischaemic heart disease have few or no physical signs and a characteristic history of peripheral vascular disease may be elicited. Key features in the cardiovascular history are shown in Box 3.1.

Box 3.1 Important Features in the Cardiovascular History

Chest pain: | onset
| duration
| nature
| precipitating factors
| relieving factors
| distribution and radiation
| previous episodes
| associated symptoms (nausea, vomiting, pallor)
Breathlessness: | on exertion
| orthopnoea
| paroxysmal nocturnal dyspnoea
Cough: | with or without sputum production
Oedema: | ankle swelling
| swelling of lower limbs and sacral area
Syncope: | on exertion
| postural
| sudden
Calf pain: | intermittent claudication
Peripheral vascular disease (PVD): | cold peripheries with colour/sensory changes
Others: | transient hemiparesis

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