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To The Reader:
Pray thee, take care, that tak'st my book in hand
To read it well: that is to understand.
—Ben Jonson

Far beyond being a text describing how to perform a history and physical exam, DeGowin's Diagnostic Examination is, uniquely, a text to assist clinicians in thinking about symptoms and physical signs to facilitate generation of reasonable, testable diagnostic hypotheses. The clinician's goal in performing a history and physical examination is to generate these diagnostic hypotheses. This was true for Hippocrates and Osler and remains true today. The practice of medicine would be simple if each symptomor sign indicated a single disease. There are enormous numbers of symptoms and signs (we cover several hundred) and they 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. To master the diagnostic process, a clinician must have four essential attributes:

  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 to elicit the pattern of symptoms and signs from each patient.
  3. Experience: Comprehensive experience with many diseases and patients, each thoroughly evaluated, allows the skilled clinician to generate a probabilistic differential diagnosis, a list of those diseases or conditions most likely to be causes of this patient's illness.
  4. Judgment: Knowledge of medical science and the medical literature combined with experience reflected upon hones the judgment necessary to know when and how to test these hypotheses with appropriate laboratory tests or 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 performing 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 ninth 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, 35 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. Understanding pathophysiology gives us the tools 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 blue) 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. Textbook of Medical Physiology. 10th ed. Philadelphia: W.B. Saunders Company: 2000. Lingappa VR, Farey K. Physiological Medicine: A Clinical Approach to Basic Medical Physiology. New York, NY: McGraw-Hill; 2000]. In addition, each chapter discusses common syndromes associated with that body region, to provide you with 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 I introduces the conceptual framework for the diagnostic process in Chapter 1, the essentials of history taking and documentation in Chapter 2, and the screening physical examination in Chapter 3. Part I and Chapter 17, which introduces the principles of diagnostic testing, should be read and understood by every clinician.

Part II, 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 and each 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 fromthe 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 exam are included, mostly from the Rational Clinical Examination series published over the last 15 years in the Journal of the American Medical Association. They are included with the caveat that they evaluate the physical exam as a hypothesis-testing tool, not as a hypothesis generating task; their emphasis on transforming the qualitative hypothesis generating task of the history and physical examination into a quantitative hypothesis testing task is 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 Hillary Beaver MD, Associate Professor Clinical Ophthalmology (Chapter 7); Jane Engeldinger, MD, Professor, Clinical Obstetrics and Gynecology (Chapters 10 and 11); John Lee, MD, Assistant Professor, Department of Otolaryngology (Chapter 7); Christopher J. Goerdt, MD, MPH, Associate Professor, Clinical Internal Medicine, Division of General Internal Medicine (Chapters 1–3, 16, and 17); 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); Marta Vanbeek, MD, MPH, Clinical Assistant Professor, Department of Dermatology (Chapter 6); and Michael Wall, MD, Professor of Neurology and Ophthalmology (Chapters 7 and 14).

For the first time color photographs are included to supplement the drawings. Dr. Hillary Beaver supplied the eye and fundus photographs, courtesy of the University of Iowa Department of Ophthalmology. The other photos were taken by the author (RFL) in his office practice.

Once again, Mr. Shawn Roach has done an excellent job of revising many of the illustrations for this edition. I greatly appreciate his patience and cooperation. Mrs. Denise Floerchinger was instrumental in coordinating my schedule and keeping me on task. Her support in this and my many other projects and clinical activities is essential to my success and is gratefully acknowledged.

My co-authors for this edition, Donald D. Brown, MD, and Richard L. DeGowin, MD, have been instrumental in seeing that the ninth edition maintains the strengths of previous editions. 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.

I am especially thankful for the continuing contributions and encouragement of Dr. Richard L. DeGowin during the extensive revisions for eighth edition and preparations for this ninth edition. He is a wonderful colleague and friend to whom I am ever thankful for the opportunity to edit this edition of DeGowin's Diagnostic Examination.

Mr. James Shanahan, our editor at McGraw-Hill, has been actively involved from the beginning in the planning and execution of the ninth edition. His encouragement and support are deeply appreciated. The McGraw-Hill editorial and publishing staff under his direction, especially Samir Roy, have been prompt and professional throughout manuscript preparation, editing, and production.

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 (please include “DeGowin's” on the subject line).

Richard F. LeBlond, MD, MACP
Iowa City, Iowa

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