30,99 €
Clinical Medicine Lecture Notes provides a comprehensive, accessible introduction to the management and treatment of medical conditions. A short manual of techniques on communication and physical examination in Part 1 is supported by the core knowledge required on diseases specific to each body system in Part 2.
Combining readability with high quality illustrations, this seventh edition has been thoroughly revised to reflect up to date practice in examination and clinical investigation, and advances in the evidence base supporting modern day clinical practice. Numerous figures and tables help distil the information for revision purposes, and there are new chapters on the medical interview and assessment.
Whether you need to develop your knowledge for clinical practice, or refresh that knowledge in the run up to examinations, Clinical Medicine Lecture Notes will help foster a systematic approach to the clinical situation for all medical students and hospital doctors.
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 847
Veröffentlichungsjahr: 2012
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.
Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK
The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
111 River Street, Hoboken, NJ 07030-5774, USA
For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell
The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.
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 BradleyMark GurnellDiana Wood
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 RubensteinDavid WayneNovember 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 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
SkillExamplesContent skillsWhat the doctor communicatesKnowledge-based: appropriate questions and responses; accurate information gathering and explanation to patient; clear discussion of investigation and treatments based on knowledgeProcess skillsHow the doctor communicatesSkills-based: verbal and non-verbal communication skills; relationship building; organising and structuring the interviewPerceptual skillsWhat the doctor is thinkingAttitude-based: clinical reasoning and problem-solving skills; attitudes towards the patient; feelings and thoughts about the patient; awareness of internal biasesProviding 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 sessiongathering information (including from physical examination)explanation and planningclosing the sessionThroughout the consultation:
organisationrelationship buildingThe 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.
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.
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 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.
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.
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.
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.
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.
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
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.
Note
joint disorders – arthritis, gout, deformityneuromuscular changes – muscle wasting, loss of functionskin temperatureCheck for
anaemia: examine the insides of the eyelids, look for glossitis (pernicious anaemia) and angular cheilitisdental hygiene, tonsillar enlargement, buccal pigmentation inside the mouthCardiorespiratory system
cyanosis: examine the underside of the tongueobserve pursing of the lips on expiration in obstructive airways diseaselupus pernio indicates sarcoidosisGastrointestinal system
jaundice – examine the scleraspider naeviPeutz–Jeghers syndromehereditary haemorrhagic telangiectasiaNeurological 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 zosterptosis and oculomotor palsiesParkinsonismmyopathy: cataract and frontal baldness suggest dystrophia myotonicaophthalmic herpes zoster including the conjunctivaEndocrine system
Observe typical features of
thyrotoxicosis: including thyroid eye disease in Grave's diseasehypothyroidismCushing syndromeacromegalyPaget's disease involving the skullAuto-immune diseases
systemic lupus erythematosus – photosensitive ‘butterfly rash’scleroderma – microstomia, tightening of the skindermatomyositis – ‘heliotrope’ periorbital rashSkin diseases
acne vulgarisacne rosaceapsoriasis: check behind the earsport wine stainRheumatological system
gouty tophi – check the pinnaeExamine
the jugular venous pressure (JVP)the thyroid glandcervical lymph nodes including the occipital groupWith shoulders relaxed examine
anterior, posterior and lateral walls and apices of axillae for lymphadenopathyExamine systematically in women and men where indicated
nipplesfour quadrants of each breastaxillary tails of each breastaxillaeFigure 2.1 Breast examination. (a) Inspection. (b) Palpation. (c) Non-dominant hand stretching the skin. (d) Examination of the axilla.
Cardiorespiratory system
pitting oedema – note the extent of peripheral oedemaevidence of peripheral vascular disease – absent foot pulses, delayed capillary filling, ulceration, gangrenevaricose veins – note and examine formally if presentulceration – note whether venous or arterialassess the temperature of the dorsum of each foot, noting asymmetry, interdigital infection and loss of hairpalpate the dorsalis pedis and posterior tibial pulsespalpate the popliteal and femoral pulsesauscultate for bruits over femoral pulsesRheumatological system
obvious joint deformity consistent with specific arthritides including goutbone deformity – Paget's disease in the tibiaeNeurological system
Charcot jointsperipheral neuropathyeffects of chronic neurological lesions – UMN (stroke), multiple sclerosis, poliosubacute combined degeneration of the cord; hereditary ataxiasSkin
cellulitisvaricose eczema with haemosiderosispsoriasisspecific skin lesions – erythema nodosumEndocrine system
pretibial myxoedemapyoderma gangrenosumLymphadenopathy
A systematic approach to the detection of lymphadenopathy is required. Examine all the major lymph nodes in a logical order:
cervicalsupraclavicularaxillaryinguinal.If lymphadenopathy is detected, examine the abdomen for hepatosplenomegaly.
Chapter 3
Cardiovascular System
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.
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
Lesen Sie weiter in der vollständigen Ausgabe!
