The Diagnostic Examination

In order to observe one must learn to compare. In order to compare one must have observed. By means of observation knowledge is generated; on the other hand knowledge is needed for observation. And he observes badly who does not know how to use what he has observed. The fruit grower inspects the apple tree with a keener eye than the walker but no one can see man exactly unless he knows it is man who is the measure of man.

The art of observation applied to men is but a branch of the art of dealing with men.

– Berthold Brecht

“Speech to Danish Working Class Actors on the Art of Improvisation”

Early learn to appreciate the differences between the descriptions of disease and the manifestations of that disease in an individual—the difference between the composite portrait and one of the component pictures.

– Sir William Osler

Not only to perceive the thing sharply, but to perceive the relationships between many things sharply perceived.

– Theodore Roethke

“Poetry and Craft”

This section presents the classic approach to diagnosis, evolved over 2000 years, in which the diagnostic clues to diseases and syndromes are sought as symptoms (abnormalities perceived by the patient’s own senses and conveyed to the physician during the history) and physical signs (abnormalities perceived by the physician’s senses and found during the physical examination).

Each chapter is organized in the following sequence:

• A brief review of the Major Systems to be examined, including the physiology and anatomic landmarks to keep in mind during the examination.

• The Physical Examination of the body region.

• The Symptoms commonly elicited from patients, which refer the clinician to this body region.

• The Signs the clinician may encounter during the examination of this region.

• The Diseases and Syndromes commonly encountered in this region.

The symptoms and signs are set in boldface type as paragraph heads, with or without preceding modifiers. These are the authors’ choices for clues that are often most important in understanding the pathophysiology of the illness and in formulating diagnostic hypotheses. Most of the key symptoms commonly occur as chief complaints. The diseases and syndromes so marked are those that the generalist physician should be able to recognize.

Symptoms, signs, and syndromes marked with the icon · are those of potentially extreme seriousness for the patient. The clinician needs to always be alert for these symptoms, signs, and conditions to avoid delayed diagnosis of life-threatening conditions.

Most of the physical signs are placed in order as they are encountered by the physician who conducts the head-to-foot physical examination of the patient.

When particular symptoms and signs are useful to help the clinician in differentiating between the various etiologies of a particular symptom or sign, they are discussed after the DDX: notation. This will help formulation of an accurate differential diagnosis.

The distinction between symptoms and signs is frequently unclear. For instance, jaundice may be a symptom that brings the patient to the physician, but it is also a sign visible to the clinician. In instances where the finding can be either a sign or a symptom, it is generally discussed where it is most likely to be found during the examination. Vomiting, although it can be witnessed, is more often a symptom, whereas tenderness, although it may be noted by the patient, is a sign that can be elicited by the examiner.

Diseases and syndromes in which the symptoms and signs occur are listed under CLINICAL OCCURRENCE.