To The Reader:
Pray thee, take care, that tak'st my book in hand
To read it well: that is to understand.
Far beyond being a text describing how to perform a
history and physical exam, DeGowin's Diagnostic Examination
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:
DeGowin's Diagnostic Examination
- Knowledge: Familiarity with the pathophysiology, symptoms, and
signs of common and unusual diseases.
- 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.
- 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
- 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.
used by students and clinicians for over 40 years precisely because of its
usefulness in this diagnostic process:
It describes the techniques for obtaining a complete history and
performing a thorough physical examination.
It links symptoms and signs with the pathophysiology of disease.
It presents an approach to differential diagnosis, based upon the
pathophysiology of disease, which can be efficiently tested in the
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
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
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.
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
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.
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.
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
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
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
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 firstname.lastname@example.org
(please include “DeGowin's” on the subject line).
Richard F. LeBlond, MD, MACP
Iowa City, Iowa