Preface

—Ben Jonson

The clinician’s goal in performing a history and physical examination is to generate diagnostic hypotheses. This was true for Hippocrates and Osler and remains true today. The purpose of DeGowin’s Diagnostic Examination is to encourage a thoughtful, systematic approach to the history, physical examination, 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 infinite number of combinations and temporal patterns. These symptoms and signs are the rough fibers from which the clinician must weave a clinical narrative, anatomically and pathophysiologically explicit, 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 develops familiarity with the presenting symptoms and signs of a wide variety of pathophysiologic processes allowing him to generate a probabilistic differential diagnosis for each new patient.

(4) Judgment: Knowledge of medical science and the medical literature, combined with reflective experience, develops the judgment necessary to efficiently test the hypotheses in the laboratory or by clinical interventions [Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet. 2003;362:1100–1105].

DeGowin’s Diagnostic Examination has been used by students and clinicians for over 40 years precisely because of its usefulness in this diagnostic process:

(1) It describes the techniques for obtaining a complete history and performance of a thorough physical examination.

(2) It links symptoms and signs with the pathophysiology of disease.

(3) It presents an approach to differential diagnosis, based upon the pathophysiology of disease, which can be efficiently tested in the laboratory.

(4) It does all of this in a format that can be used as a quick reference at the “point of care” and as a text to study the principles and practice of history taking and physical examination.

In undertaking this tenth edition of a venerable classic, my goal is once again to preserve the unique strengths of previous editions, while adding recent information and references, reducing redundancy, and improving clarity. The second edition is one of the few books I have retained from medical school, 40 years ago. 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.

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 findings, we need to think pathophysiology. Pathophysiology and pathologic anatomy provide the framework to understand disease as alterations in normal physiology and anatomy, and illness as the patient’s experience of these changes.

A discussion of pathophysiology (highlighted in the second color) 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 [Guyton AC, Hall JE. Guyton and Hall Textbook of Medical Physiology. 12th ed. Philadelphia, PA: W.B. Saunders Company: 2011]. 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. Part 1 and Part 4, Chapter 17, which introduces the principles of diagnostic testing, should be read and understood by every clinician.

Part 2, Chapters 4 through 14, 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 to 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 will find this useful and not too cumbersome.

References to articles from the medical literature are 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 evaluation of common and unusual clinical problems, and, in some cases, photographs illustrating key findings. 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 field 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 over the last 20 years 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. The emphasis on transforming the qualitative hypothesis generating task of the history and physical examination into a quantitative hypothesis testing task is, I think, misguided [Feinstein AR. Clinical Judgement revisited: the distraction of quantitative models. Ann Intern Med. 1994;120:799–805].

Each chapter was independently reviewed by faculty members of the University of Iowa Roy J. and Lucille A. Carver College of Medicine. Their feedback and assistance is gratefully acknowledged. Reviewers for this edition are Jane Engeldinger, MD, Professor, Clinical Obstetrics and Gynecology (Chapters 10 and 11); Christopher J. Goerdt, MD, MPH, Associate Professor, Clinical Internal Medicine, Division of General Internal Medicine (Chapters 1–4); Vicki Kijewski, MD, Assistant Professor of Clinical Psychiatry and Internal Medicine (Chapter 15); Victoria Jean Allen Sharp, MD, MBA, Clinical Associate Professor, Departments of Urology and Family Medicine (Chapters 10 and 12); William B. Silverman, MD, Professor, Clinical Internal Medicine, Division of Gastroenterology and Hepatobiliary Diseases (Chapter 9); Haraldine A. Stafford, MD, PhD, Associate Professor, Clinical Internal Medicine, Division of Rheumatology (Chapter 13); and Michael Wall, MD, Professor of Neurology and Ophthalmology (Chapters 7 and 14).

My co-authors for this edition, Donald D. Brown, MD, Joseph Szot MD, and Manish Suneja MD, have been instrumental in seeing that the tenth edition maintains the strengths of previous editions while continuing to evolve to meet the reader’s needs. Dr. Brown directed the history taking and physical examination course at the University of Iowa for over 25 years. He is annually nominated for best teacher awards by the students in recognition of his knowledge and enthusiasm for teaching these essential skills. As a practicing cardiologist, he is the primary editor for Chapters 8 and 16. Dr. Szot is a general internist and Dr. Suneja is a general internist with subspecialty certification in Nephrology. They are Associate Program Directors in the University of Iowa Internal Medicine Residency Program.

This is the first time that DeGowin’s Diagnostic Examination does not have direct participation by the DeGowin family of physicians. We, of course, are building on the solid foundation they have built and which we will continue to honor with the book’s title.

Ms. Christine Diedrich and Mr. James Shanahan, our sponsoring editors, and Mr. Robert Pancotti, our project development editor, at McGraw-Hill, have been actively involved from the beginning in the planning and execution of the tenth edition. Their encouragement and support are deeply appreciated. The McGraw-Hill editorial and publishing staff have been prompt and professional throughout manuscript preparation, editing, and production.

For the tenth edition, a standard e-book edition is available, as is an enhanced e-book edition that includes embedded video segments demonstrating fundamental physical examination procedures. We have included complimentary access to five of these videos in the standard print and e-book editions. The videos are available at: mhprofessional.com/diagnosticexam/

I wish to thank my colleagues who have encouraged me throughout the course of this project. I have incorporated many suggestions from my co-authors and each of the reviewers; any remaining deficiencies are mine. Ultimately, you, the reader, will determine the strengths and weaknesses of this edition. I welcome your feedback and suggestions. Email your comments to rleblond@billingsclinic.org (please include “DeGowin’s” on the subject line).