Read with two objectives: first 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.
—Sir William OslerDeGowin's Diagnostic Examination
“The Student Life”
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. Proper use of the laboratory and imaging are based upon accurate
diagnostic hypotheses generated while taking the history and performing the
physical examination. 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 diseases. From the history and
physical examination, the clinician generates a set of testable
pathophysiologic and diagnostic hypotheses—the differential diagnosis.
Acquisition of proficiency and confidence in generating this differential
diagnosis is the purpose for this book. It is this differential diagnosis
that is subjected to laboratory testing.
of the American Board of Internal Medicine have expressed concern about the
atrophy of diagnostic skills among trainees and have recommended
improvements in training programs [Schechter GP, Blank LL, Godwin HA Jr,
LaCombe MA, Novack DH, Rosse WF. Refocusing of history-taking skills during
internal medicine training. Am J Med.
point out that overreliance on technology has contributed to loss of
clinical bedside skills. DeGowin's Diagnostic Examination
to assist the student and clinician in making reasonable diagnostic
hypotheses from the history and physical examination. Part I, Chapters 1 to
3, discuss the diagnostic framework in detail. Chapter 1 discusses the
importance of diagnosis and the process of forming a differential diagnosis
specific to each patient. Chapter 2 discusses the process of history taking
and documentation of your findings in the medical record. Chapter 3 presents
an outline of the screening physical examination.
The heart of DeGowin's Diagnostic Examination
is Part II, Chapters 4
to 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 specific body
region. Chapters 6 to 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 neurologic examination (Chapter 14), and the psychiatric and social
evaluations (Chapter 15).
Parts III and IV
provide supplemental information. Chapter 16 discusses the preoperative
examination. The intent is to give the reader a framework for evaluating the
medical risks of surgical procedures and an approach to communicating those
risks to the patient and surgeon. Chapter 17 introduces the principles of
laboratory testing and imaging. These principles are critical to an
efficient use of the laboratory and radiology. Chapter 18 lists many common
(not “routine”) laboratory tests that provide important
information about the patient's condition not accessible from the history or
physical examination. More specialized tests used to evaluate specific
diagnostic hypotheses are not discussed.
6 to 14 have a uniform organization: (A) each chapter begins with a brief
overview of the major organ systems to be considered; (B) next is a
discussion of the superficial and deep anatomy of the body region; (C) the
physical examination of the region or system is described in detail in the
usual order of performance; (D) the symptoms particularly relevant to the
body region and systems are presented; (E) the physical signs in the region
or system exams are listed (some findings can be both symptoms and signs;
discussion of a finding is in the section where it is most likely to be
encountered, then cross referenced in the other section); and (F) discusses
diseases and syndromes commonly in the differential diagnosis of symptoms
and signs in the body region and systems under discussion. To avoid
duplication, the text is heavily cross-referenced.
Brief discussions of many diseases and clinical syndromes are included so
the reader can appreciate the patterns of symptoms and signs they commonly
manifest. This will help the clinician determine whether that disease or
syndrome should be included in the differential diagnosis of the symptoms
and signs in their specific patient. Particularly useful points of
differentiation are listed after the DDX
symbol.DeGowin's Diagnostic Examination
is not a textbook
of medicine. The reader must use this with a comprehensive textbook of
medicine to fully understand the diseases and syndromes. We strongly
recommend Harrison's Principles of Internal Medicine
as a companion
text [Kaspar DL, Braunwald E, Fauci AS, et al., eds. Harrison's
Principles of Internal Medicine.
17th ed. New York, NY: McGraw-Hill;
We emphasize the characteristics of
diseases because a clinician who knows the manifestations of many diseases
will ask the right questions, obtain the key history, and elicit the
pertinent signs that differentiate one disease from another. Instructions on
how to elicit the specific signs are included in the physical examination
section for each region; if the maneuver is not part of the usual exam, it
is discussed with the sign itself. Following the descriptions of many
symptoms and signs is a highlighted Clinical Occurrence
section. This is a list of diseases often associated with the symptomor
sign. The organization of the Clinical Occurrence section is based upon the
approach to the differential diagnosis of the symptom or sign felt to be
most useful clinically.
Where a broad
differential exists, we have introduced anorganizational scheme for the
Clinical Occurrence based upon the pathophysiologic mechanisms of disease.
The clinician can often narrow their differential diagnosis to one or a few
basic mechanisms of disease: congenital, endocrine, idiopathic, infectious,
inflammatory/immune, mechanical/traumatic, metabolic/toxic, neoplastic,
neurologic, psychosocial, or vascular. This facilitates the creation of a
limited yet reasonable differential diagnosis. The categories in this scheme
are not mutually exclusive; a congenital syndrome may be metabolic,
infections are usually accompanied by inflammation, and a neoplastic process
may cause mechanical obstruction. Although not rigid, this is a useful
conceptual construct for thinking about the patient's problems.
Key symptoms, signs, syndromes, and diseases are
highlighted. These are important in understanding common disease processes.
Critical symptoms, signs, syndromes, and diseases are noted by the
marginal symbol. These are symptoms,
signs, syndromes, and diseases that may indicate an emergent condition
requiring immediate and complete evaluation.
using our understanding of normal and abnormal anatomy and physiology as the
basis for thinking within clinical medicine, it is possible to avoid the
trap of “word space.” This is the term one of us (RFL) has given
to the common practice of using lists and word association as a means of
thinking (or, rather not thinking) about diagnosis: associating a word (for
instance, cough) with a memorized list of other words (pneumonia,
bronchitis, asthma, postnasal drip, gastroesophageal reflux, etc.). The
emphasis on memorization inherent in this scheme is the bane of all medical
students; fortunately, it is not only unnecessary, it is counterproductive.
Cough is a protective reflex arising from sensory phenomena in the upper
airway, bronchi, lungs, and esophagus mediated through peripheral and
central nervous system pathways and executed by coordinated contraction of
the diaphragm, chest wall, and laryngeal muscles. With this physiologic
context, and our understanding of the mechanisms of disease, we can
hypothesize the irritants most likely to be relevant in each specific
New diseases are being encountered with
surprising frequency. They present not with new symptoms and signs, but with
new combinations of the old symptoms and signs. It is our hope that the
reader will learn to recognize the patterns of known diseases and to be
alert for patterns that are unfamiliar (those not yet in their knowledge
base) or previously unrecognized (the new diseases). HIV/AIDS was recognized
as an unprecedented clinical syndrome with a new pattern of familiar
symptoms (weight loss, fever, fatigue, dyspnea, cough) and signs (wasting,
generalized lymphadenopathy, mucocutaneous lesions, Kaposi's sarcoma,
opportunistic infections) in a unique population (homosexual males and IV
drug users). Continuously expanding our personal knowledge of the known
while welcoming the unfamiliar and unknown is the excitement of clinical
The proper testing of specific
diagnostic hypotheses is beyond the scope of this book. It is subject to
constant change as new tests are developed and their usefulness evaluated in
clinical trials. Part IV discusses the principles of laboratory testing
(Chapter 17) and some common laboratory tests (Chapter 18). The reader
should consult Harrison's Principles of Internal Medicine,
edition, and the current literature when selecting specific tests to
evaluate their diagnostic hypotheses [Guyatt G, Rennie D, eds. Users'
Guides to the Medical Literature: A Manual for Evidence-Based Clinical
Chicago, IL: AMA Press; 2002].
User's Guide:DeGowin's Diagnostic Examination
can be read cover to cover with
benefit to the student or practitioner; however, most will not, and should
not, choose this strategy. As Osler said, read to understand your patients
and to answer your questions.
We strongly suggest
that all readers start with Chapters 1 to 3 and 17, which outline the
conceptual basis for the diagnostic examination, including the approach to
laboratory testing and imaging. This context is critical to an efficient use
of time and resources.
If you have questions
about the systems being examined in a given body region consult part A of
the relevant chapter and Harrison's Principles of Internal Medicine,
17th edition. If your question concerns anatomy, consult part B and an
anatomy textbook. If you are uncertain of the techniques of the physical
examination, see Chapter 3 and part C of the body region chapters. If you
are uncertain what to make of a symptom, see part D of the relevant chapter.
If you are wondering how to elicit or interpret a particular sign, see part
E of the relevant chapter. To find out more about the diseases mentioned in
the section, consult part F of that chapter or look in the index for the
page where it is discussed. Remember, the disease and syndrome discussions
in this book are brief and must be complemented with reading in a textbook
of medicine, e.g., Harrison's Principles of Internal Medicine,
The Table of Contents should be scanned
to familiarize yourself with the structure and general content of the text.
You can always consult the index to find the location of any of the material
in the text.
There is no right way to use a book.
The key is to use the information to inform your thinking about patients and
the problems they present. No text is definitive and the reader is
encouraged to consult other texts and the current and historic literature to
develop a full understanding of your patients and their illnesses. The
acquisition of clinical skills is a journey without end; this is an
intimidating thought for the student, but is the source of lifelong
stimulation for the practitioner.After
all, what we call truth is only the hypothesis which is found to work best.
—Sir James George Frazer