DeGowin's Diagnostic Examination Flashcards - 1st Edition

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 R
TENTh Ed ITION
D eGow in’s
D iagnostic Examination
Richard F. LeBlond , MD, MACP
Professor Emeritu s of Internal Med icine
The University of Iow a Carver College of Med icine
Iow a City, Iow a

Donald D. Brow n, MD, FACP

Professor of Internal Med icine
The University of Iow a Carver College of Med icine
Iow a City, Iow a

Manish Su neja, MD, FASN

Associate Professor of Internal Med icine
The University of Iow a Carver College of Med icine
Iow a City, Iow a

Josep h F. Szot, MD, FACP

Associate Professor of Internal Med icine
The University of Iow a Carver College of Med icine
Iow a City, Iow a

Illustrated by
Elm er DeGow in, MD, Jim Abel, and Shaw n Roach

N ew York Chicago San Francisco Athens Lond on Mad rid Mexico City Milan
N ew Delhi Singap ore Syd ney Toronto
Copyright © 2015 by McGraw-Hill Education. All rights reserved. Except as permitted
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To obta in ma te ria l from the dis k tha t
a ccompa nie s the printe d ve rs ion of
this e Book, ple a s e c lic k h e re .
 To ou r p atients,
w ho allow u s to p ractice ou r art,
encou rage u s w ith their con d ence,
and hu m ble u s w ith their cou rage.

— Ric h a Rd F. Le BLo n d
 New
Flashcards based
on the classic text!
A fun, fast, carry-anywhere way to learn how to
perform a complete diagnostic examination

These ashcards will help

you to brush up on your
diagnostic examination
procedural skills by asking
questions that test your
knowledge and provide
answers that impart must-
know information.
Each of the 250 two-sided
cards contains an open-
ended question with a
concise, bulleted answer
on the ip side. This unique
review focuses on the
diagnoses most frequently 0-07-182909-1 • 978-0-07-182909-0
tested on the USMLE Step $40.00
2 and 3 examinations.
 It is not easy to give exact and complete details of an operation in writing; but
the reader should form an outline of it from the description.
—h ip p o c Ra t e s
“O n JOin t s ”

[Studies] perfect nature, and are perfected by experience: for natural abilities
are like natural plants, that need pruning, by study; and studies themselves,
do give forth directions too much at large, except they be bounded in by experience.
Crafty men contemn studies, simple men admire them, and wise men use
them; for they teach not their own use; but that is a wisdom without them, and
above them, won by observation. Read not to contradict and confute; nor to
believe and take for granted; nor to nd talk and discourse; but to weigh and
consider.
—FRa n c is Ba c o n
“O f s t u d ie s ”

A little observation and much reasoning lead to error; many observations and a
little reasoning to truth.
—d R. a Le x is c a RRe L

It is only by persistent intelligent study of disease upon a methodical plan of

examination that a man gradually learns to correlate his daily lessons with the
facts of his previous experience and that of his fellows, and so acquires clinical
wisdom.
— s iR W iLLia m o s Le R

Sources for Quotations:

Brecht qu otation from : Bertolt Brecht. Poems, 1913–1956. Lond on, Methu en Lond on Ltd .,
1979.

Eliot qu otation from : T.S. Eliot. The Complete Poems and Plays, 1909–1950. N ew York,
H arcourt, Brace & World , Inc., 1971.

Frazer quotation from : Sir Jam es George Frazer. The Golden Bough, A Study in M agic and
Religion, abrid ged ed ition. N ew York, MacMillan Pu blishing Com pany, 1922.

H ip pocrates qu otation from : Jacqu es Jouanna (M.B. DeBevoise translator). H ipp ocrates.
Baltim ore, The Johns H op kins University Press, 1999.

Osler qu otation from : Sir William Osler. A equanimitas, with other A ddresses to M edical Students,
N urses and Practictioners of M edicine. Philad elp hia, P. Blakiston’s Son and Co., 1928.
Roethke qu otations from : Theod ore Roethke. On Poetry and Craft. Port Tow nsend ,
Washington Cop p er Canyon Press, 2001.

vii
This page intentionally left blank
 R CONTENTs
Preface xxv
Com m on Abbreviations xxix
Introd u ction and User ’s Gu id e xxxi

pa r T 1
Th E d Ia g NOsTIC Fr a mEw Or k

1. d Ia g NOsIs 2
1. Why Is Diagnosis Im portant? 2
2. Diseases and Synd rom es: Com m u nication and
Entry to the Med ical Literature 2
A. The D iagnostic Examination 3
1. Stories: Listen, Exam ine, Interpret, Explain 3
2. Find ing Clues to the Diagnosis 4
3. Select H ypotheses: Generate a Differential Diagnosis 5
4. Cognitive Tests of the Diagnostic H yp otheses 8
5. Selection of Diagnostic Tests 9
6. Rare Diseases 9
7. Certainty and Diagnosis 10
8. Prognostic Uncertainty 10
9. Deferred Diagnoses 10
10. A Su m m ary of the Diagnostic Process 11
11. Caveat 12
12. An Exam ple of the Diagnostic Process 12
B. Other Examinations 12
1. The Au top sy 12
2. Other Varieties of Med ical Exam inations 13

2. h IsTOr y Ta k INg a Nd Th E mEd ICa l r ECOr d 14

A. Outline of the Medical Record 14
B. Procedure for Taking a History 15
1. Description of the Med ical H istory 15
2. Scope of the H istory 15
3. H ow to Take a H istory 15
4. Do N ot Make Assum ptions 16
C. Completion of the Medical Record 17
1. Id enti cation 17
2. The Inform ant 18
3. Chief Com plaints 18
4. Past Med ical and Surgical H istory 20
5. Fam ily H istory 21
6. Social H istory 21
7. Military H istory 21

ix
x Contents

8. Review of System s 22
9. Gynecologic H istory 24
10. Male H istory 24
11. Venereal Disease H istory 24
12. Med ications 25
13. Allergies and Med ication Intolerances 25
14. Preventive Care Services 25
15. Ad vance Directives 25
16. Physical Exam ination 25
17. Laboratory 25
18. Assessm ent 25
19. The Plan 26
D. The Oral Presentation 26
E. Other Clinical N otes 27
1. Inpatient Progress N otes 27
2. Off-Service N ote 27
3. Discharge Sum m ary 27
4. Clinical N otes 27
F. The Patient’s Medical Record 27
1. Pu rposes 28
2. Physician’s Signature 28
3. Cu stod y of the Record 28
G. Electronic Medical Records 29

3. Th E sCr EENINg ph ysICa l Ex a mINa TION 30

A. Methods for Physical Examination 31
1. Insp ection 31
2. Palp ation 32
3. Percu ssion 33
4. Au scu ltation 35
B. Procedure for the Screening Physical Examination 37
1. Prep aring for the Screening Exam ination 39
2. Perform ance of the Screening Exam ination 39
C. Ultrasound in Bedside D iagnosis 43
1. Technical Consid erations 43
2. Scope of Ultrasou nd in Diagnostic Exam ination 45

pa r T 2
Th E d Ia g NOsTIC Ex a mINa TION
The D iagnostic Examination: Chapters 4 to 16 48

4. VITa l sIg Ns, a NTh r OpOmETr IC d a Ta , a Nd pa IN 49

A. Vital Signs 49
1. Bod y Tem p erature 49
2. The Pu lse: Rate, Volum e, and Rhythm 57
3. Exam ination of the Pu lse 58
4. Breathing: Resp iratory Rate and Pattern 66
5. Blood Pressure and Pu lse Pressu re 68
Contents xi

B. Anthropometric D ata 74
1. H eight 74
2. Weight 75
C. Pain 79
1. Diagnostic Attribu tes of Pain 80
2. Pain Synd rom es 81

5. NONr Eg IONa l sysTEms a Nd d IsEa sEs 82

A. Constitutional Symptoms 82
1. Fatigu e 82
2. Distu rbance of App etite 83
3. Distu rbance of Thirst 84
4. Constitu tional Synd rom es/ Diseases 84
B. The Immune System 85
1. Com m on Im m u nod e ciency Synd rom es 86
C. The Lymphatic System 86
1. Exam ination of the Lym p h N od es 87
2. Lym ph N od e Sym p tom s 89
3. Lym ph N od e Diseases and Synd rom es 89
4. Diseases and Synd rom es of Speci c Regional
Lym ph N od es 91
5. Disord ers of B Cells/ Plasm a Cells 94
D. The Hematopoietic System and Hemostasis 95
1. Red Blood Cell (Erythrocyte) Disord ers 95
2. N eu trop hil Disord ers 97
3. Myelop roliferative Disord ers and Acute Leukem ia 97
4. Platelet Disord ers 98
5. Coagu lation Disord ers 99
E. The Endocrine System 100
1. Diabetes and H ypoglycem ia 100
2. Disord ers of Thyroid Function 101
3. Disord ers of Ad renal Fu nction 103
4. Disord ers of Parathyroid Function 104
5. Disord ers of Pitu itary Fu nction 105

6. Th E sk IN a Nd Na Il s 1 06
A. Physiology of the Skin and N ails 106
B. Functional Anatomy of the Skin and N ails 106
1. Epid erm is 106
2. Derm is and Subcutaneous Tissu e 107
3. Fingernails 107
4. Toenails 107
5. Skin Coloration 109
6. H air 109
7. Sebaceou s Gland s 109
8. Eccrine (Sw eat) Gland s 110
9. Apocrine Gland s 110
10. N erves 110
11. Circulation of the Skin and Mucosa 110
12. Cu taneou s Wound H ealing and Repair 110
xii Contents

C. Examination of the Skin and N ails 111

1. Evalu ation of Skin Tu rgor 111
2. Exam ination of N ailfold Capillaries 111
D. Supplemental Aids to D ermatologic D iagnosis 111
1. Magni cation 111
2. Diascopy 111
3. KOH Prep aration 112
4. Tzanck Sm ear 112
5. Wood Light 112
6. Skin Biop sy 112
E. Skin and N ail Symptoms 112
1. Itching (Pru ritus) 112
F. Skin and N ail Signs 113
1. Anatom ic Distribution of Lesions 113
2. Pattern of Lesions 113
3. Morp hology of Ind ivid u al Lesions 115
4. Generalized Skin Signs 119
5. Changes in Skin Color 122
6. Changes in H air 124
7. Fingernail Signs 125
G. Foot and Toenail Signs 129
H. Vascular Signs 130
1. Arterial Circu lation Signs 131
2. Pu rpu ra 133
3. N onp urp uric Vascu lar Lesions 134
I. Signs of Systemic Lipid D isorders 138
1. Xanthom as 138
J. Common Skin and N ail Syndromes 138
1. Com m on Skin Disord ers 138
K. Skin Infections and Infestations 143
1. Insects, Spid ers, Mites, and Worm s 143
2. Bacterial Infections 144
3. Viral Infections 147
4. Fu ngal Infections 149
5. Bu llous Skin Diseases 150
6. Skin Manifestations of System ic Diseases 150
7. Vascu lar Disord ers 155
8. Skin N eoplasm s 157

7. Th E h Ea d a Nd NECk 160
A. Major Systems of the Head and N eck 160
B. Functional Anatomy of the Head and N eck 161
1. The Scalp and Skull 161
2. The Face and N eck 161
3. The Ears 162
4. The Eyes 163
5. The N ose 166
6. The Mouth and Oral Cavity 168
7. The Larynx 170
8. The Salivary Gland s 171
9. The Thyroid Gland 172
Contents xiii

C. Physical Examination of the Head and N eck 173

1. Exam ination of the Scalp, Face, and Sku ll 173
2. Exam ination of the Ears, H earing, and
Labyrinthine Fu nction 173
3. Testing Labyrinth Fu nction 175
4. Examination of the Eyes, Visual Fields, and
Visual Acuity 176
5. Exam ination of the N ose and Sinu ses 182
6. Exam ination of the Lip s, Mou th, Teeth, Tongu e,
and Pharynx 184
7. Exam ination of the Larynx 186
8. Exam ination of the Salivary Gland s 186
9. Exam ination of the Tem porom and ibular Joint 187
10. Exam ination of the N eck 187
11. Exam ination of the Lym ph N od es 188
12. Exam ination of the Vascu lar System 188
D. Head and N eck Symptoms 188
1. General Sym ptom s 188
2. Sku ll, Scalp, and Face Sym p tom s 188
3. Ear Sym p tom s 189
4. Eye Sym ptom s 190
5. N ose Sym ptom s 191
6. Lip, Mouth, Tongu e, Teeth, and Pharynx
Sym ptom s 191
7. Larynx Sym ptom s 192
8. Salivary Gland Sym p tom s 192
9. N eck Sym ptom s 192
E. Head and N eck Signs 193
1. Scalp, Face, Sku ll, and Jaw Signs 193
2. External Ear Signs 195
3. External Acou stic Meatus Signs 196
4. TM Signs 197
5. H earing Signs 197
6. Eye Lid Signs 197
7. Eye Movem ent Signs 201
8. Conju nctiva Signs 201
9. Cornea Signs 203
10. Sclera Signs 204
11. Pu pil Signs 205
12. Lens Signs 205
13. Retina Signs 206
14. N ose and Sinus Signs 215
15. Breath Signs 219
16. Lip Signs 220
17. Teeth and Gum Signs 224
18. Tongu e Signs 226
19. Pharyngeal Signs 230
20. Larynx and Trachea Signs 230
21. Salivary Gland Signs 232
22. N eck Signs 234
23. Mid line Cervical Mass 235
xiv Contents

24. Lateral Cervical Masses 236

25. Thyroid Signs 237
F. Head and N eck Syndromes 238
1. Squ am ou s Cell Cancers of the H ead and N eck 238
2. Scalp, Face, Sku ll, and Jaw Synd rom es 239
3. Eye Synd rom es 240
4. Ear Synd rom es 242
5. N ose and Sinus Synd rom es 246
6. Oral Syndromes (Lips, Mouth, Tongue, Teeth, and Pharynx) 249
7. Larynx Synd rom es 252
8. Salivary Gland Synd rom es 255
9. Thyroid Goiters and N od ules 255

8. Th E Ch EsT: Ch EsT wa l l , p l mONa r y, a Nd

Ca r d IOVa sC l a r sysTEms; Th E Br Ea sTs 260
sECTION 1
C e t w , pu on , n C iov cu s te 260
A. Major Systems and Physiology 260
1. The Thoracic Wall 260
2. The Respiratory System 261
3. The Lungs and Pleu ra 263
4. The Card iovascu lar System 265
B. Super cial Thoracic Anatomy 266
1. The Chest Wall 266
2. The Lungs and Pleu ra 268
3. The H eart and Precord ium 268
C. Physical Examination of the Chest and Major Vessels 270
1. Insp ection of the Rib Cage and Thoracic Mu scu latu re 270
2. Palp ation of the Rib Cage and Thoracic Mu scu latu re 270
3. Exam ination of the Lu ngs and Pleu ra 272
4. Physical Exam ination of the H eart and Precord iu m 276
5. Physical Exam ination of the Blood Vessels 280
6. Examination of the Arterial Circulation in the Extremities 284
7. Exam ination of the Large Lim b Veins 287
D. Chest, Cardiovascular, and Respiratory Symptoms 287
1. General Sym ptom s 287
2. Chest Wall Sym ptom s 290
3. Lung and Pleural Sym p tom s 291
4. Card iovascu lar Sym ptom s 291
E. Chest, Trachea, and Respiratory Signs 292
1. Chest Wall Signs 292
2. Trachea Signs 297
3. Lung, Pleu ra, and Resp iratory Signs 298
4. Vibratory Palpation 299
5. Sonorou s Percu ssion 299
6. Au scu ltation of Breath Sou nd s 300
7. Au scu ltation of Voice Sou nd s 301
8. Au scu ltation of Abnorm al Sound s 302
9. Interp retation of Pulm onary and Pleural Signs 302
10. Sp u tu m Signs 307