To The Reader:
Pray thee, take care, that tak’st my book in hand
To read it well: that is, to understand.
The purpose of taking a clinical history and performing the physical exam is to generate diagnostic hypotheses. This was true for Hippocrates and Osler and remains true today. DeGowin’s Diagnostic Examination encourages a thoughtful, systematic approach to the history, physical exam, 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 raw materials from which the clinician must weave an anatomically and pathophysiologically explicit clinical narrative 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 becomes familiar with the presenting symptoms and signs of a wide variety of pathophysiologic processes allowing generation of a probabilistic differential diagnosis for each patient.
(4) Judgment: Knowledge of basic medical science and the medical literature, combined with reflective experience, promotes the judgment necessary to efficiently test diagnostic hypotheses in the laboratory or by clinical interventions.
DeGowin’s Diagnostic Examination has been used by students and clinicians for over 50 years precisely because of its usefulness in honing this diagnostic process:
(1) It describes the techniques for obtaining a complete history and performing a thorough physical exam.
(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 point-of-care reference and as a text to study the principles and practice of history taking and physical examination.
In undertaking this eleventh edition of a venerable classic, our goal is once again to preserve the unique strengths of previous editions, while adding recent information and references, reducing redundancy, and improving clarity. 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. We remain true to the original goal of this book which was to encourage a thoughtful systematic approach to diagnosis based on history and physical examination. In this edition at the end of chapter 4 to 16 you will also find examples of clinical vignettes (followed by questions) demonstrating essential concepts used in framing diagnostic hypothesis. The answers to these questions can be found in the Appendix. Along with the factual information stored in long-term memory, these vignettes will help facilitate development and implementation of diagnostic strategies using memory schemes that represent and interrelate clinical problems.
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 for understanding 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. 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. Every clinician needs a thorough understanding of Part 1 and Part 4, Chapter 17, the latter introducing the principles of diagnostic testing.
Part 2, Chapters 4 through 15, 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 through 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 finds this useful and not too cumbersome.
References to articles from the medical literature are sparingly 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 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.
Each chapter was independently reviewed by faculty members. Their feedback and assistance are gratefully acknowledged. Reviewers for this edition are Bimal Ashar, MD, MBA, Division of General Internal Medicine, Johns Hopkins University School of Medicine (Chapters 5 and 16), Karolyn Wanat, MD, Department of Dermatology, Medical College of Wisconsin, (Chapter 6), Doug Van Daele, MD, Department of Otolaryngology, University of Iowa Hospitals & Clinics (Chapter 7), Karl Thomas, MD, Department of Internal Medicine, Wake Forest School of Medicine (Chapter 8), Christopher J. Goerdt, MD, MPH, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine (Chapter 9), Aash Bhatt, MD, Department of Internal Medicine, Western Michigan University, Homer Stryker School of Medicine (Chapter 10), Abby Hardy-Fairbanks, MD, Department of Obstetrics and Gynecology, University of Iowa Roy J. and Lucille A. Carver College of Medicine (Chapter 11), Chad Tracy, MD, Department of Urology, University of Iowa Roy J. and Lucille A. Carver College of Medicine (Chapter 12), Chadwick Johr, MD, University of Pennsylvania Perelman School of Medicine (Chapter 13).
All editors for this edition, Manish Suneja, MD, Joseph Szot, MD, Richard F. LeBlond and Donald D. Brown, MD, have been instrumental in seeing that the eleventh edition maintains the strengths of previous editions while continuing to evolve to meet the reader’s needs.
Ms. Kay Conerly is the senior editor at McGraw Hill for the eleventh edition. She has been actively involved in the planning and execution of the eleventh edition. Her encouragement and support are deeply appreciated. The McGraw Hill editorial and publishing staff have been prompt and professional throughout manuscript preparation, editing, and production.
The eleventh edition includes video segments demonstrating fundamental physical examination procedures. Complimentary access to these videos is available at: www.mhprofessional.com/DeGowinsDiagnosticExam.
Finally, we wish to thank our colleagues who have encouraged us throughout the course of this project. We have incorporated many suggestions from our reviewers/readers and would like to thank those who have taken the time to write recommendations for this edition. Ultimately, you, the reader, will determine the strengths and weaknesses of this edition. We welcome your feedback and suggestions.
Manish Suneja, MD, FACP, FASN
Joseph Szot, MD, FACP
Richard F. LeBlond, MD, MACP
Donald D. Brown, MD, FACP
Iowa City, Iowa