Sapira’s Art & Science of Beside Diagnosis

688 Pages·2010·11.16 MB·English

by  Jane M. Orient

Sapira’s
Art & Science of
Bedside Diagnosis
F E
O U R T H D I T I O N
Jane M. Orient, M.D.
Clinical Lecturer in Medicine
University of Arizona College of Medicine
Tucson, Arizona
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Library of Congress Cataloging-in-Publication Data
Orient, Jane M.
Sapira’s art & science of bedside diagnosis / Jane M. Orient.—4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978–1–60547–411–3 (alk. paper)
1. Physical diagnosis. 2. Medical history taking. I. Sapira, Joseph D., 1936– II. Title. III. Title: Sapira’s
art and science of bedside diagnosis. IV. Title: Art & science of bedside diagnosis. V. Title: Art and science
of bedside diagnosis.
[DNLM: 1. Medical History Taking. 2. Physical Examination. WB 200 O69s 2010]
RC76.S25 2010
616.07´54—dc22
2009030914
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C
O N T E N T S
Preface to the Fourth Edition VII The Evasive Patient 38
Preface to the First Edition VIII The Uncooperative (“Noncompliant”) Patient 39
Acknowledgments IX Dealing with Fantasies 40
The Patient Who Begins to Cry 40
1 Introduction 1 The Patient Who Is Undiagnosable 41
The Demanding Patient 41
How to Use This Book 1
The Patient Who Denies the Relevance of Psychologic
A Disclaimer 2
Factors 42
Diagnostic Equipment of Purchase 2
The Science of Clinical Examination 4 APPENDIX 2.1 Abbreviated Cognitive Examination 42
The Art of Clinical Examination 5 APPENDIX 2.2 Reasons For Identifying the Patient with
Dementia 42
Ethical Foundations 5
Defi nitions 6 APPENDIX 2.3 Answer to the Self-test on the CAGE Test 42
Further Reading 42
Evaluation of Diagnostic Signs: More Defi nitions 8
References 43
Evidence-based Medicine 13
APPENDIX 1.1 Answer to the Question on the Stethoscope 15 3 The History 44
APPENDIX 1.2 Answer to the Question on Incidence and
Importance of the History 44
Prevalence 15
The Difference between Facts and Information 44
APPENDIX 1.3 Analysis of Example on Testing Sequence 15
Overview of History of Present Illness 44
APPENDIX 1.4 Answer to the Self-study Question on Prior and
Chief Complaint 45
Posterior Probabilities 15
Dimensions of a Symptom 45
APPENDIX 1.5 Answer to the Self-study Question on NNT 15
Associated Symptoms 48
References 15
Abbreviated History in Trauma Patients 48
Elaboration of Selected Symptoms 48
2 The Interview 17
A Philosophical Interlude on “Diseases” and “Syndromes” 59
First Principles of the Interview 17 Use of Diagnostic Conclusions 59
Interviewing Style 17 Past Medical History 59
Assessing and Improving Your Interviewing Skills 22 Social History 60
Autognosis 24 Sexual History 61
Last Question in the Interview 25 A History of Abuse 63
The Psychodynamic Termination of the Physical Examination 25 Drug History 63
Notes on Offi ce-based Practice 25 Dietary and Nutritional History 64
Interviewing Patients Who Are Forgetful or Confused 26 A Note to the Student 65
Approach to the Elderly Patient 30 References 66
The Patient Who Seems to Be Changing His Story 31
The Patient Who Is Vague 31 4 The Case Record 68
The Patient Who May Be Addicted to Drugs or Behaviors 32
Introduction 68
The Patient Who May Be Involved in Illegal Activities 33
Model Outline of Gerry Rodnan, MD 70
The Patient Who May Have Other Legal Involvements 34
Comments on Historic Information 72
The Pseudopatient 34
General Considerations on Authoring the Medical Record 73
The Patient Who Might Have a Factitious Disease 34
Chief Complaint 73
Sexual Orientation 35
The “Problem-Oriented” Medical Record 74
The Patient Who Is a Member of a Subculture with Its Own
History of the Present Illness 74
Jargon 35
Past Medical History 76
The Non–English-speaking Patient 35
Social History 76
The Patient Who Cannot Hear Well 36
Review of Systems 76
The Patient Who Cannot Read Well 36
Physical Examination 77
The Hostile Patient 36
Differential Diagnosis 80
The Patient Who Refers to Himself as a “Guinea Pig” 36
Laboratory Data 80
The Patient Who Will Only Be Examined by a “Real
Bedside Presentation 81
Doctor” 37
APPENDIX 4.1 Forgacs Notation: Pathophysiologic
The Patient Who Asks Personal Questions 37
Explanations 82
The Organ Recital (or “by the Way, Doctor…”) 37
APPENDIX 4.2 A Spanish–English Case Record 82
The Aphasic Patient 37
References 84
iii
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iv Contents
5 General Appearance 85 Exophthalmos (Proptosis) 173
Extraocular Movements 173
A Method 85
The Sclera 176
Position and Posture 86
The Conjunctiva 177
Movements 87
The Cornea 178
Habitus and Body Proportions 88
The Red Eye 180
Is the Patient in Pain? 88
The Anterior Chamber 181
Is the Patient Dehydrated? 89
The Iris 184
Is the Patient Malnourished? 89
Pupils 184
Cleanliness and Grooming 89
Ophthalmoscopic Examination 189
Self-study: Speculation 89
Ophthalmoscopic Findings 193
References 89
APPENDIX 10.1 Answers to Questions on Pupillary Light
Refl ex 220
6 The Vital Signs 90
APPENDIX 10.2 Answer to Question in Fig. 10-34 220
Blood Pressure 90 APPENDIX 10.3 Six Pearls of Clinical Ophthalmoscopy for the
The Pulse 101 Primary Care Physician and Medical Consultant 220
Respiration 107 APPENDIX 10.4 Why Did House Staff Miss the Findings of Carotid
Temperature 108 Occlusive Disease? 220
References 112 References 220
7 Integument 115
11 The Ear 224
Skin 115
External Inspection 224
Hair 138
Internal Inspection 226
Nails 141
Nonotologic Causes of Otalgia 228
APPENDIX 7.1 Answers to the Self-test in Fig. 7-1 146
Auscultation 228
APPENDIX 7.2 Answers to the Question in Fig. 7-4 146
Special Maneuvers 229
APPENDIX 7.3 Answer to Self-test on Café Au Lait Spots in
APPENDIX 11.1 Earlobe Crease: Sensitivity, Specifi city, and
Neurofi bromatosis 146
Predictive Value 234
APPENDIX 7.4 Answer to the Question in Fig. 7-6 and a Note
APPENDIX 11.2 Testing the Diagnosis of a Blocked Eustachian
on Terminology (Expressions of Ignorance) 146
Tube 234
APPENDIX 7.5 Predictive Value of Skin Tags for the Presence of
APPENDIX 11.3 Answer to Question in Legend to
Colonic Polyps 147
Figure 11-4 234
APPENDIX 7.6 Koilonychia in a Well-Baby Clinic 147
References 234
References 147
8 Lymph Nodes 151 12 The Nose 236
Dimensions 151 External Appearance 236
Lymph Node Groups 151 Internal Appearance 236
Evaluating the Clinical Signifi cance of Lymph Nodes 155 Special Maneuvers: Sense of Smell 240
APPENDIX 8.1 What is Wrong with the Story about Osler? 155 References 240
References 155
13 The Oropharynx 242
9 The Head 157
Order of Examination 242
Inspection 157 Oral Aperture 243
Palpation 162 Lips 243
Percussion 164 Tongue 244
Auscultation 164 Other Finding 245
Special Maneuvers: Transillumination 166 Teeth 245
A Note on Head and Facial Pain 166 Gums (Gingiva) 247
References 167 Palate 247
Buccal Mucosa 249
10 The Eye 168
Noma 251
Order of the Examination 168 Throat 251
Visual Acuity 168 Findings in Patients with Obstructive Sleep Apnea 252
Visual Fields 169 Larynx 253
The Lacrimal Apparatus 170 A Bouquet of Odors 253
The Eyelids and Other Periorbital Tissue 171 References 255
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Contents v
14 The Neck 258 Heart Failure? 363
Apparent Combination Lesions 363
Contour 258
Nonprecordial Murmurs 364
Deep Space Infections 258
A Comparison of Clinical Examination with Doppler
Thyroid 258
Echocardiography 365
Parathyroid Glands 262
A Note on Cardiopulmonary Resuscitation 366
Trachea 262
More Advanced Imaging 366
Salivary Glands 263
APPENDIX 17.1 Massive Pericardial Effusion and the PMI 366
References 264
APPENDIX 17.2 Answer to Self-Study on Page 323 367
15 The Breast 266 APPENDIX 17.3 Why Laënnec Could Hear Better Than He Could
Palpate 367
History: Risk Factors for Breast Cancer 266
APPENDIX 17.4 Key to Fig. 17-11 367
Draping the Female Patient 267
APPENDIX 17.5 Differential Diagnosis of a Murmur 367
Inspection 267
APPENDIX 17.6 Self-test on Mitral Valve Prolapse 367
Palpation 268
APPENDIX 17.7 CPC Diagnosis: A Case in Which a Murmur Similar
Auscultation 270
to That of Mitral Stenosis Was Not Mitral Stenosis 367
Discharge from the Breast 270
APPENDIX 17.8 The Auenbrugger Sign 367
Gynecomastia 271
APPENDIX 17.9 When Is Congestive Heart Failure Not Congestive
APPENDIX 15.1 Predictive Value of the Results of Screening Heart Failure? 367
Mammography 271
References 367
APPENDIX 15.2 Results of Testing Nipple Discharge for Occult
Blood 272 18 Arteries 372
References 272
Carotid (and Vertebral) Arteries 372
16 The Chest 274 Temporal Arteries 382
Subclavian Artery 382
Inspection 274
Axillary and Brachial Arteries 383
Palpation 279
Wrist Arteries 383
Percussion 281
The Raynaud Phenomenon 384
Auscultation 289
Aorta 385
Special Maneuvers 299
Penile Artery 387
Synthesis 307
Renal Arteries and Other Causes of Abdominal Bruits 387
APPENDIX 16.1 Auscultatory Percussion for the Detection of Arteries of the Lower Extremities 390
Pleural Effusion 314
Pedagogic Inspiration 393
APPENDIX 16.2 Answer to the Self-test on the Specifi city of Microvasculature 393
Auscultatory Percussion, Page 304 314
Peripheral Perfusion and Shock 393
APPENDIX 16.3 Answers to Self-test on Diagnostic Findings, Other Vascular Conditions 393
Figs. 16-17–16-22. 314
APPENDIX 18.1 Answer to Question on Page 386 394
APPENDIX 16.4 Predictive Value of Diminished Breath Sounds for APPENDIX 18.2 Discussion of Case Report 394
the Detection of Moderate COPD 315
APPENDIX 18.3 Answer to Self-study on Page 389 394
References 315
References 394
17 The Heart 318
19 Veins 398
Inspection 318
Venous Pressure 398
Palpation 319
Jugular Venous Pulsations 406
Percussion 321
Auscultation 409
Auscultation 324
Venous Syndromes 410
Special Maneuvers 344
Synthesis 346 APPENDIX 19.1 The Circulation Time 413
Aortic Insuffi ciency 351 APPENDIX 19.2 Answer to Self-test on the Kussmaul Sign 414
Aortic Stenosis 351 APPENDIX 19.3 Diagnosticity of the Abdominojugular Refl ex 414
References 415
Mitral Insuffi ciency 354
Mitral Stenosis 357
20 The Abdomen 417
Pulmonic Insuffi ciency 359
Pulmonic Stenosis 359 Inspection 417
Tricuspid Insuffi ciency 360 Palpation 419
Tricuspid Stenosis 362 Percussion 423
Pericardial Effusion 362 Auscultation 423
When Is (Apparent) Congestive Heart Failure Not Congestive Special Maneuvers 424
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vi Contents
Synthesis 425 The Appendicular Skeleton: Joints and Associated Parts 504
APPENDIX 20.1 Differential Diagnosis of the Patient in Peripheral Nerve Injuries and Entrapment Neuropathies 515
Fig. 20-5 437 APPENDIX 25.1 Myopathy: Answer to Question (in an Exercise
APPENDIX 20.2 Which Side Has the Perinephric Abscess? 437 for the Student) 523
APPENDIX 20.3 Answer to Self-study on Differential APPENDIX 25.2 Answer to Question in Figure 25-2 Legend 523
Diagnosis 437 References 523
References 437
26 The Neurologic Examination 526
21 Male Genitalia 440
Overview 526
Penis 440 Cranial Nerves 527
Scrotum 443 Skilled Acts 544
Testes, Epididymis, and Spermatic Cords 445 Meningitis 547
Hernias 447 Posture 548
Prostate and Seminal Vesicles 448 Movement Disorders 551
References 448 Coordination 556
Motor Examination 563
22 Female Genitalia 449 Refl exes 569
Overview 449 Sensory Testing 579
External Genitalia 451 Autonomic Nervous System 588
Vaginal Examination 456 Intracranial Lesions 588
Bimanual Examination 460 Selected Neurologic Symptoms or Diagnoses 591
Synthesis 463 Consciousness, Stupor, and Coma 596
References 463 Cognition 600
Functional Imaging in Encephalopathy 612
23 The Rectum 465 A Coda on the Patient with a Chronic Neurologic Illness 612
APPENDIX 26.1 Answer to Self-study Question on the Red Glass
Preparing the Student 465
Test 612
Preparing the Patient for Examination 465
APPENDIX 26.2 Self-test on the Corneal Refl ex 612
Examination 466
APPENDIX 26.3 Why Parkinson Could Not Detect
Findings 466
Cogwheeling 612
Alleged Adverse Effects of the Rectal Examination 468
APPENDIX 26.4 Delusions 612
Special Maneuver: Anoscopy 469
APPENDIX 26.5 Assessment of Affect 613
Screening for Colorectal Cancer 469
APPENDIX 26.6 Hysteria 613
APPENDIX 23.1 Answer to Self-study (Signs of Sexual Abuse) 469
APPENDIX 26.7 The Brief MAST (Pokorny et al., 1972) 613
APPENDIX 23.2 Answer to Self-study (Prostatic Nodules) 469
References 613
References 469
27 Clinical Reasoning 620
24 The Extremities 471
Principles of Clinical Reasoning 620
Upper Extremities 471
Differential Diagnosis 624
Lower Extremities 481
APPENDIX 27.1 Analysis for the Problem in Logical Fallacies
APPENDIX 24-1. Answer to Self-study (Nodules in Rheumatoid
Section 632
Arthritis and Rheumatic Fever) 486
APPENDIX 27.2 A Method for Solving the Problem in Diagnosis by
APPENDIX 24.2 Answer to Question in Fig. 24-2 Legend 486
Exclusion Section 632
APPENDIX 24.3 Answer to Question in Fig. 24-8 Legend 486
References 632
APPENDIX 24.4 Answer to Question in Fig. 24-9 Legend 486
APPENDIX 24.5 A Note on the Pit Recovery Time: Answers to 28 Some Bedside Laboratory Tricks 633
Questions in Fig. 24-13 486
Blood 633
References 486
Urine 640
25 The Musculoskeletal System 488 Other Body Fluids and Secretions 645
The Future of Diagnostic Testing 648
Muscle Disorders 488
References 649
Bone 491
The Tensegrity Model 493
29 Annotated Bibliography 651
Basic Principles of Examination 493
Index 654
The Axial Skeleton 497
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P F
R E F A C E T O T H E O U R T H E D I T I O N
From the day when the fi rst members of councils placed exterior behavior of patients and physicians, there remains the problem that
authority higher than interior, that is to say, recognized the human beings are not stamped from an industrial die. Even if not
totally unique in genetic endowment, each human being has had a
decisions of men united in councils as more important and more
different interaction with the world.
sacred than reason and conscience; on that day began lies that
As the art of medicine is being lost, the science is also threatened.
caused the loss of millions of human beings and which continue
“Evidence-based” medicine is coming to mean based on the consensus
their unhappy work to the present day. of a committee of experts: the Prussian Geheim Rath with many heads
—LEO TOLSTOY (and no heart). Clinical reasoning is replaced by following a prac-
tice “guideline” from one prescribed information bit to another, and a
Since the fi rst edition went to press, the revolution has pro- diagnosis means a number with fi ve signifi cant digits (never mind that
ceeded apace. At hospital committee meetings these days, the dis- the fi rst one is dubious) attached to an appropriate procedure code.
connection between medicine as once taught by prerevolutionary The very altar of truth—the autopsy table—is being dismantled.
physicians and medicine as now codifi ed by compliance-minded, It is telling that bureaucratic quality assessment is almost always
MBA-qualifi ed “medical directors” is startling; the author feels as based on process (read compliance) measures such as number of
though she arrived at such meetings by time machine. blood pressure determinations or prescriptions for the medica-
In the new “integrated delivery systems,” the organizational tion du jour, not outcome measures such as all-cause mortality or
chart reigns. Physicians are boxed into defi ned categories, next to ability to function independently. Regardless of the reading on the
the bottom of the chart, just above the patients; together with the “continuous quality improvement” dashboard, almost everyone on
patients (now known as “covered lives”), they form the “medical the front lines of patient care believes that American medicine and
loss ratio.” health are in decline.
It is a world of paradox. Talk of “ethics” generally means talk of Why, then, another edition of this book?
“resource allocation,” often by means once called unethical. One Medicine is a living thing that will survive and fl ourish, despite
drowns in information, but the key of knowledge is lost. Facilities the dinosaurs of “health care delivery,” and long after inhuman sys-
and personnel are present in excess, and yet they are scarce. tems fail. There are still students who aspire to be physicians, not
The scarcest item of all appears to be the clinician’s time. Thirty providers, gatekeepers, resource managers, or box-checkers. There
seconds may be too long to spend searching for a reference. In some are still those who consider medicine to be a human and a humane
settings, there may be no time to look in the left ear if only the right endeavor, not an industry. This book is to provide them a compass,
one hurts, much less to listen to the patient’s grief or despair. And a road map, and, perhaps, a little entertainment as they embark on
when can today’s managed provider stop and refl ect? an exciting journey of exploration, together with their most impor-
Concepts are imported from industry, such as “six sigma tant teachers: their patients.
quality”—the goal to reduce errors below 6 standard deviations As students begin their foray into physical diagnosis, frequently
from the mean of a normal distribution. This means that all but 3.4 feeling overwhelmed by the vast amount of data they must absorb,
out of 1 million patients are supposed to meet a certain indicator, the most helpful piece of advice might be that offered in 1957 by
such as timely Pap smears or mammograms, regardless of individ- neurologist Robert Wartenberg: “Mistakes in neurologic diagnosis
ual needs and desires. are more likely to result from not looking enough than from not
Quality experts in industry do recognize that one cannot con- knowing enough.”
trol outputs without controlling inputs—a fact that health policy
experts seldom acknowledge. But even if we could control the —Jane M. Orient, M.D., 2009
vii
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P F
R E F A C E T O T H E I R S T E D I T I O N
As the decay of the Chou Dynasty grew worse, studies were neglected 19th century translator of Galen, who believed that medicine could
and the scribes became more and more ignorant. When they did be greatly improved only if the ignorant physicians of his day had
access to Galen’s work. After devoting his life to translating Galen
not remember the genuine character, they blunderingly invented a
into modern languages, he found that his task had immediately
false one. These non-genuine characters, copied out again by other
become an exercise in obsolescence, due to the beginning of the
ignorant writers, became usual.
scientifi c era of medicine. Yet, one daily observes patients for whom
—L. WIEGER, SJ, CHINESE CHARACTERS the history and physical examination could lead one to the correct
diagnosis hours, days, and even weeks before it can be achieved by
The goal of this book is to help the reader achieve the correct those who rely solely on modern technology. And for some diagno-
personal, metaphysical, and epistemologic perspectives on the artful ses (e.g., vascular headache, depression, irritable colon), there is no
science of clinical examination. This is not a textbook of medicine. substitutive technology.
In analogy to football, a textbook of medicine is the playbook. This Plowing through this tome, learning what you can, and noting
book is about learning the skills of blocking, tackling, punting, pass- other passages for future use is hopefully part of your initiation into
ing, and so forth, so that one may execute the plays with diligence a very special and elite club. This club collects no dues and has no
and facility. scheduled meetings (although you can attend a meeting any time
The style is intentionally unusual, attempting to capture the you wish by picking up a book). It is founded on a certain value
excitement of actual rounds with diversions along the way. This hierarchy, irrespective of dramatic changes in technology, and exists
should help to hold the attention of today’s students and residents, in the dimension of time, mostly irrespective of place.
who are often caught up in pointless memorizing and unproduc- The tradition of clinical examination dates back 2,500 years
tive errand-running at the expense of scholastic preparation for the or earlier. The author of this book, who is attempting to help
lifelong task of self-teaching. train you, was trained by Dr Jack Myers, who was trained by
This book is written with a sense of great sadness about American Dr Soma Weiss. With suffi cient scholarly effort, it would be pos-
academic medicine and from a prerevolutionary point of view (the sible to trace a lineage from any reader back to Laënnec or even
revolution in academic medicine having occurred about 1968,1 to Hippocrates.
when the intellectual approach to diagnosis and its attendant tech- We owe a great debt to those who taught us. The only way to
niques of clinical examination fell into disrespect, superseded by an repay the debt is to transmit the knowledge to the next generation,
inappropriately exclusive reliance on dogma and modern techno- insofar as it is possible. In every hospital and every school that I
logic devices). If the current civilization preserves even more trivial visit, I meet young persons of the prerevolutionary type. This book
records of its behavior than did the Sumerian culture, then the pres- is for them.
ent text may be of interest to historians of future ages. Some may
think that this book will be held in the same regard as the work of a —Joseph D. Sapira, M.D., 1989
1 Chargaff, working independently from completely different observa-
tions, also selects 1968 as the year of revolution. (See Chargaff E. H eraclitean
Fire: Sketches from a Life Before Nature. New York: Rockefeller University
Press; 1978.)
viii
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A
C K N O W L E D G M E N T S
I cannot begin to thank all those who helped me learn c linical For the third edition, I am indebted to many more, including
medicine. I still sometimes feel as though Dr Albert Grokoest, my Dr Ashish Goel for a highly perceptive overall review and many use-
physical diagnosis instructor at Columbia College of Physicians ful comments; Dr Chester Danehower for his critique of Chapter 7
and Surgeons, is looking over my shoulder, admonishing me to pay and additional illustrations; Drs Michael A. J. Robb and Laurence
attention to the patient and not just the technical details. Dr George Marsteller for insights into tinnitus and otoneurologic problems; Dr
Wales King, Tucson family physician, let me follow him around for a Curtis Caine for pearls on airway management; Dr Del Meyer for
whole summer, teaching me something of the meaning of physician- reviewing Chapter 16; Dr Brendan Phibbs for critiquing C hapter 17
hood. Dr Marianne Legato provided exemplary bedside teaching and offering many clinical pearls; Dr Stuart Danovitch for contrib-
at Roosevelt Hospital in the City of New York. Dr Donald Seldin, uting to Chapters 20 and 23; Dr A. Lee Dellon for the discussions
Chairman of the Department of Medicine at Texas Southwestern, of peripheral nerve injuries and sensory testing; Dr Rene Allen for
taught me that even the Professor needs to go to the bedside and reviewing Chapter 22; Dr Richard Neubauer for information on
examine the patient fi rsthand. Dr Rubin Bressler, Chairman of the hyperbaric oxygenation; Dr Philip James for invaluable insights into
Department of Medicine at the University of Arizona, taught me multiple sclerosis; Drs Sam Paplanus and Ron Spark for reviewing
that the most important thing was not the adherence to the pro- Chapter 28; and countless others. Drs Gervais and Huntoon once
tocol of the moment but the answer to the question: “How is the again gave hours of their time for updating and correcting Chapters
patient doing?” 10 and 26.
I am deeply indebted to Dr Sapira for inviting me to help with For the fourth edition, I am also grateful to Dr Alan Rapoport
the fi rst edition of this book. for insights into likelihood ratios and into the differential diagnosis
Many busy practicing physicians gave generously of their time of apparent “lymph nodes” and for pointing out several errors in
to review parts of this book and to contribute additional mate- the text; Dr F. Edward Yazbak for reviewing portions of the text
rial. Those who helped with the second edition include Drs Joseph concerned with pediatrics; Dr Timothy Fagan for helpful correc-
Scherzer, Don Printz, and Claud Boyd, Jr (Chapter 7); Drs Michael tions and suggestions to Chapter 6; Dr Tamzin Rosenwasser for
Schlitt and Miguel Faria (Chapters 9 and 26); Dr Robert Gervais help with Chapter 7 and questions on the integument; Dr Angela
(Chapter 10); Drs Vernon L. Goltry and John H. Boyles, Jr Lanfranchi for many contributions to the discussion of the breast
( Chapters 11 to 14); Dr Jerome Arnett (Chapter 16); Drs Eddie examination; Dr Jerome Arnett for many useful additions and cor-
Atwood and Rachel Marcus (Chapter 17); Dr W. Daniel J ordan rections to Chapter 16; Dr Karen Smith for making me aware of
(Chapters 18 and 19); Dr Sheldon Marks (Chapter 21); Drs Devra the importance of cervical spine disease in rheumatoid arthritis;
Marcus and Sara Imershein (Chapter 22); Dr James Klein (Chapter 23); Dr Edward Harshman for a method for determining the level of
Drs Thomas Dorman and John Dwyer (Chapters 24 and 25); and spinal cord injury by checking intercostal muscle function; and
Dr Lawrence Huntoon (Chapter 26). I thank Drs Joseph Scherzer, Dr John Minarcik for reviewing Chapter 28.
Michael Schlitt, and Devra Marcus for contributing photographs, Research for this book was made possible by the assistance
and Dr Huntoon for contributing drawings. Dr William Summers of Marcia Arsenault (second edition) and Michelle Bureau (third
added to the discussion of dementia in Chapter 26. Dr D.R. Royall and fourth editions), Librarians Extraordinaire, of Carondelet St
provided the executive interview in Chapter 26. Raquel Pérez, Joseph’s Hospital in Tucson, Arizona, and to Carondelet St Joseph’s
R.N., helped with the revision of the Spanish–English database. Drs for the use of its library resources.
Milne J. Ongley and Thomas Dorman instructed me in examination I also thank Jeremy Snavely for computer consultation; my
techniques used in orthopedic medicine, and Dr Dorman granted s ister Ruth Stensrud and my mother Phyllis Orient for tolerance,
unstinting permission to reprint illustrations from Diagnosis and assistance in innumerable practical ways, and proofreading; Emily
Injection Techniques in Orthopedic Medicine by Thomas A. Dorman and Snavely for clerical assistance and proofreading; and Patti Wylie for
Thomas H. Ravin, Williams and Wilkins, Baltimore, 1991. numerous photographs.
ix
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