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INTRODUCTION

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”

THE DIAGNOSTIC EXAMINATION: CHAPTERS 4 TO 15

This section, organized by body region, explains the diagnostic utility of the symptoms and signs commonly associated with each region, often with a brief summary of the relevant physiology.

Each chapter is organized in the following sequence:

  • A brief review of the Major Systems examined, including relevant physiology, and anatomic landmarks.

  • The Physical Exam of the region.

  • The Symptoms commonly associated with region.

  • The Signs commonly encountered during examination of this region.

  • The Diseases and Syndromes associated with symptoms and signs in the region.

The symptoms and signs are set in boldface type as paragraph heads. These are clues to the pathophysiology of each disease which is important for accurate diagnostic hypotheses. The key symptoms are commonly chief complaints. The clinician should be familiar with the diseases and syndromes summarized in the last subsection.

Symptoms, signs, and syndromes marked with the icon ● signal the need for urgent evaluation to avoid delaying diagnosis of a life-threatening condition.

The signs are placed in approximate order as they are encountered during the head-to-foot physical exam.

When particular symptoms and signs are useful in differentiating between the various etiologies, they are discussed after the DDX: notation.

Some findings are both a symptom and a sign. For instance, severe jaundice can be both the patient’s symptom and a clinical sign. In these instances, the finding is discussed where it most commonly occurs: vomiting is most often a symptom, though it can be witnessed; tenderness, although noted by the patient, is a sign elicited by the examiner.

Diseases ...

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