Physical Diagnosis Secrets: With STUDENT CONSULT Online Access, 2e

712 Pages·2007·26.72 MB·English

by  Salvatore Mangione MD

PHYSICAL
DIAGNOSIS
Second Edition
Salvatore Mangione, MD
Associate Professor ofMedicine
Director, PhysicalDiagnosis Course
Jefferson Medical College ofThomasJefferson University
Philadelphia, Pennsylvania
1600JohnF.KennedyBoulevard,Suite1800
Philadelphia,PA19103-2899
PhysicalDiagnosisSecrets ISBN-978-0-323-03467-8
SecondEdition
CopyrightQ2008,byElsevierInc.
CopyrightQ2000,byHanleyandBelfus.
Allrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrieval
system,ortransmittedinanyformorbyanymeans,electronic,mechanical,photocopying,
recording,orotherwise,withoutpriorpermissionofthepublisher(Mosby,1600JohnF.
KennedyBoulevard,Suite1800,Philadelphia,PA19103-2899).
NOTICE
Knowledgeandbestpracticeinthisfieldareconstantlychanging.Asnewresearchand
experiencebroadenourknowledge,changesinpractice,treatmentanddrugtherapy
maybecomenecessaryorappropriate.Readersareadvisedtocheckthemostcurrent
informationprovided(i)onproceduresfeaturedor(ii)bythemanufacturerofeach
producttobeadministered,toverifytherecommendeddoseorformula,themethodand
durationofadministration,andcontraindications.Itistheresponsibilityofthe
practitioner,relyingonhisorherownexperienceandknowledgeofthepatient,tomake
diagnoses,todeterminedosagesandthebesttreatmentforeachindividualpatient,and
totakeallappropriatesafetyprecautions.Tothefullestextentofthelaw,neitherthe
PublishernortheEditorassumesanyliabilityforanyinjuryand/ordamagetopersonsor
propertyarisingoutorrelatedtoanyuseofthematerialcontainedinthisbook.
LibraryofCongressCataloging-in-PublicationData
Mangione,Salvatore,1954-
PhysicalDiagnosisSecrets/SalvatoreMangione.–2nded.
p.;cm.
Includesbibliographicalreferencesandindex.
ISBN978-0-323-03467-8
1. PhysicalDiagnosis–Miscellanea. I. Title. [DNLM: 1. PhysicalExamination–
ExaminationQuestions. 2. DiagnosticTechniquesandProcedures–Examination
Questions. 3. SignsandSymptoms–ExaminationQuestions. WB18.2M277p2008]
RC76.P5242008
616.07’54076–dc22 2007003812
SeniorAcquisitionsEditor:JamesMerritt
DevelopmentalEditor:StanWard
ProjectManager:MaryB.Stermel
MarketingManager:AlysonSherby
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DEDICATION
TomydogSpringy,whospeakssoftlybutcarriesabigstick;
andtomydaughterGemma,whodoestheopposite.
iii
iv DEDICATION
Seek,andyeshallfind.
Matthew7:7
Tobeabletoexploreis,inmyopinion,alargepartoftheArt.
Hippocrates,EpidemicsIII
ItwassixmenofIndostan,tolearningmuchinclined,
whowenttoseetheelephant(thoughallofthemwereblind),
thateachbyobservationmightsatisfyhismind.
Thefirstapproachedtheelephantandhappeningtofall,
againsthisbroadandsturdyside,atoncebegantobawl:
‘‘Godblessme!Buttheelephantisnothingbutawall!’’
Thesecond,feelingofthetusk,cried,‘‘Ho!whathavewehere,
soveryroundandsmoothandsharp?Tome’tismightyclear,
thiswonderofanelephantisverylikeaspear!’’
Thethirdapproachedtheanimal,andhappeningtotake
thesquirmingtrunkwithinhishands,‘‘Isee,’’quothhe,
‘‘theelephantisverylikeasnake!’’
Thefourthreachedouthiseagerhandandfeelsabouttheknee:
‘‘Whatmostthiswondrousbeastislike,ismightyplain,’’quothhe,
‘‘’Tisclearenoughtheelephantisverylikeatree.’’
Thefifth,whochancedtotouchtheear,said:‘‘E’entheblindestman
cantellwhatthisresemblesmost:Denythefactwhocan,
Thismarvelofanelephantisverylikeafan!’’
Thesixthnosoonerhadbegunaboutthebeasttogrope,
than,seizingtheswingingtail,thatfellwithinhisscope,
‘‘Isee,’’quothhe,‘‘theelephantisverylikearope!’’
So,oftintheologicwars,thedisputants,Iween,
treadinutterignoranceofwhateachothermean,
andprateabouttheelephant,notoneofthemhasseen!
JohnGodfreySaxe(1816–1887)
CONTENTS
Dedication iii
Contributors vii
Preface ix
Top 100 Secrets 1
1. GeneralAppearance, Facies,andBody Habitus 9
SalvatoreMangione,MD
2. VitalSigns 34
SalvatoreMangione,MD
3. The Skin 63
SalvatoreMangione,MD
4. The Eye 126
SalvatoreMangione,MD
5. The Ear 164
SalvatoreMangione,MD
6. NoseandMouth 177
SalvatoreMangione,MD
7. The Neck 205
SalvatoreMangione,MD
8. TheThyroid 216
SalvatoreMangione,MD
9. The Breast 239
SalvatoreMangione,MD
10. The Cardiovascular System 251
SalvatoreMangione,MD
11. HeartSoundsandExtraSounds 287
SalvatoreMangione,MD
12. HeartMurmurs 318
SalvatoreMangione,MD
m
vi CONTENTS
13. Chest Inspection,Palpation,andPercussion 367
SalvatoreMangione,MD
14. LungAuscultation 404
SalvatoreMangione,MD
15. TheAbdomen 445
SalvatoreMangione,MD
16. MaleGenitalia, Hernias,and RectalExam 488
SalvatoreMangione,MD
17. FemaleGenitaliaandthe Pelvis 507
SalvatoreMangione,MD
18. LymphNodes 521
SalvatoreMangione,MD
19. The NeurologicSystem 536
EnricaArnaudo,MD,andMichaelD.Kim,DO
20. The BedsideDiagnosisof Coma 573
SalvatoreMangione,MD
21. The MusculoskeletalSystem 588
SalvatoreMangione,MD
22. The Extremitiesand PeripheralVascular System 644
SalvatoreMangione,MD
Top 10+10 "Secret" Reasons Why It Is Good to Be a Doctor 663
Index 665
CONTRIBUTORS
Enrica Arnaudo,MD
ClinicalAssistantProfessorofNeurology,ThomasJeffersonUniversity,
Philadelphia,Pennsylvania;Director,NeuromuscularDiseaseProgram,
NeuroscienceandSurgeryInstituteofDelaware,Wilmington,Delaware
Michael D.Kim,MD
NeurologyFellow,ThomasJeffersonUniversity,Philadelphia,Pennsylvania
vii
PREFACE
PrefacetotheFirstEdition
Physicaldiagnosisoccupiesanuncertainpositionattheturnofthemillennium.Therehasbeen
recentinterestinvalidating,refining,andsometimesdiscardingtraditionalmethodsandsigns.
Aphysicaldiagnosisinterestgrouphasarisenwithinthegeneralinternalmedicinecommunity.
TheAmericanCollegeofPhysicianshassponsoredanupdatecourseandbibliographyon
physicaldiagnosis,andTheJournaloftheAmericanMedicalAssociationhasinitiatedaseriesof
articlesonthe‘‘rationalclinicalexamination.’’Perhapsmostimportantly,physiciansinpractice
ratehistory-takingandphysicalexaminationastheirmostvaluableskills.Ontheotherhand,
adistressingliteraturedocumentsthelackofcompetenceinphysicaldiagnosisamongprimary
careresidentsandevenphysicians-in-practice.Fewtrainingprogramsprovidestructured
teachingintheseskills,andattending‘‘rounds’’toooftenavoidthebedside.
Still,thereareplentyofreasonstopromotetheteachingofphysicalexamination.Among
thesearecost-effectiveness,thepossibilityofmakinginexpensiveserialobservations,theearly
detectionofcriticalfindings,theintelligentandwell-guidedselectionofcostlydiagnostic
technology,andthetherapeuticvalueofthephysicalcontactbetweenphysicianandpatient.In
timeswhenthe‘‘fun’’seemstohaveabandonedthepracticeofmedicine,physicaldiagnosisand
otherbedsideskillscanevenrestorethesatisfactionandintellectualpleasureofmakinga
diagnosisusingonlyourownwitsandsenses.
Inreviewingthevariousmaneuversandfindingswhich,overthecenturies,createdphysical
examination,wemadeadeliberateattemptatpresentingsomeinformationaboutthemenand
womenbehindtheeponyms(andforthiswereliedonthatgreatlittlebookbyB.G.Firkinand
J.A.Whitworth,TheDictionaryofMedicalEponyms).Webelievethatlearningaboutthe
characterandpersonalityofthesephysiciansmightshedsomelightonwhyphysicaldiagnosis
enjoyedsomanycontributionsinthelastcenturyandsofewinourown.Thegreatbedside
diagnosticiansofthelastcenturywerepassionatelyinterestedineverythinghuman.Most,ifnot
allofthem,werehumanists,loversoftheartsandliterature,travelersandhistorians,poetsand
painters,curiousofanyfieldthatcouldenrichthehumanspirit.WilliamOsler,thepinnacleof
19thcenturybedsidemedicine,believedsostronglyinthevalueofaliberaleducationthathe
providedhismedicalstudentswithalistoftenbooks(rangingfromPlutarchandMontaigneto
MarcusAureliusandShakespeare)toreadforhalfanhourbeforegoingtosleep.
AsBernardLownputsit,today’sphysicians‘‘seemattimesmoreinterestedinlayingon
toolsthanlayingonhands.’’Rejuvenatingphysicaldiagnosismight,therefore,requirearevival
ofthetime-honoredlinkbetweentheartandthescienceofmedicine.WeagreewithWilliamOsler
thatMedicineis‘‘anartofprobabilitiesandascienceofuncertainties’’andthatthesetwoaspects
areinseparable,verymuchlikeSiamesetwins:tryingtoseparateonefromtheotherwouldonly
killboth.Rekindlinginterestinthebedsideandinthehumanisticaspectofmedicine,therefore,
mayrepresenttwofacetsofthesamechallenge.WealsoagreewithSocratesthatoneofthemost
effectivewaystoteachistoquestion.WehopethatPhysicalDiagnosisSecrets,infollowingthis
ix
x PREFACE
traditionandthatoftheprovenandtime-testedSecretsSeries,willserveasavaluableand
engagingresourceforlearningandtrulyappreciatingtheartandscienceofphysicaldiagnosis.
SalvatoreMangione,MD
Philadelphia,2000
PrefacetotheSecondEdition
Itisamazinghowquicklytimeflies.WhenIwaspreparingthefirsteditionofPhysicalDiagnosis
Secrets,mydaughterwasstillsleepingin101-Dalmatiansbedsheets.Nowthatthefirstedition
hasbeenthroughfour(andsoonfive)translationsintoforeignlanguages,sheisaboutto
graduatefromcollege.Andaneweditionisreadytoprint.
Bookswewritehavebeencomparedtochildren,insofarastheyteachusthroughthe
mistakeswemake.Notthatinmycase(childorotherwise)thereweremanymistakestolearn
from,butstillitwasgoodtohaveanopportunityforrevisitingandexpandingmostofthe
chapters.Indeed,somewerealmostcompletelyrewritten.Inaddition,wedecidedtomake
availabletobookbuyerstheonlineaccesstothehighlysuccessfulHeartandLungSounds
SecretsCardio-PulmonaryAuscultationWorkshop,whichcomesfreeonceyouactivatethePIN
foundontheinsidefrontcoverbygoingtowww.studentconsult.com.Since40%ofallerrorsin
physicaldiagnosisarerelatedtothecardiopulmonaryexam,thissimplebuthelpfultoolwill
increasetremendouslytheeducationalvalueprovidedbythenewedition.Asforallother
Elsevierbooks,buyerswillalsohavecompletefreeaccesstotheInternet-basedStudent
Consult,whichnotonlyprovidesanelectronicversionofPhysicalDiagnosisSecretsbutalso
offerspicturesandaudiovisualadjuncts,plusalgorithmsthatcanhelptheuserfindaway
throughthevariousquestionsofeachchapter.
Althoughthesechangeshavesurelymadetheneweditionstronger,theyhavenotaltered
theprovenandtime-testedSocraticapproachofquestionsandanswersthathasmadethe
SecretsSeriessosuccessful.Thiseditionalsocontinuestoemphasizetheevidencebehindthe
signsandmaneuverssothatreaderscanbestsortthewheatfromchaffintheirdailypractice.
Finally,ithasmaintainedthewhodunnitapproachtoeponyms,rediscoveringthemenand
womenbehindthesigns,withalltheirquirksandrichhumanity.Weoweittothemandtheir
ingenuityifmedicineremainsascienceandanart.Inthisregard,wehopethatthefinalproduct
willcontinuetofosteralifelonginterestinthetime-honoredartofbedsideexamination,one
highlyrewardingtoitsusers,butalsohighlyendangered–especiallyinournewmillenniumof
hightechnologyandlowskills.
Asoneofthemastersofphysicalexam(JohnBreretonBarlow)usedtoputit,wededicate
thisbooktoallstudentsofmedicinewholisten,look,touch,andreflect.Maytheyhear,see,feel,
andcomprehend.
SalvatoreMangione,MD