Table Of ContentSOUND DIAGNOSIS
A HARMONIZED APPROACH TO MEDICINE
MARIA RIBEIRO
with
Gerard Hoffnung’s illustrations
Boca Raton London New York
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First published 2008 by Radcliffe Publishing
Published 2016 by CRC Press
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© 2008 Maria Ribeiro
Drawings by Gerard Hoffnung © The Hoffnung Partnership
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ISBN-13: 978-1-84619-208-1 (pbk)
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CONTENTS
Approach to common signs v
About the author and illustrator vi
Acknowledgements vii
1 An overview of what lies ahead 1
2 A guided case presentation 10
3 The ‘basicologists’ 33
4 The haematologists 43
5 The rheumatologists 59
6 The cardiologists 66
7 The nephrologists 100
8 The pulmonologists 106
9 The gastroenterologists 120
10 The neurologists 129
11 The endocrinologists 138
12 The gerontologists 151
In retrospect, what will I remember? 156
List of abbreviations 158
Dedicated to the Doctors of tomorrow
Seeking Sound Diagnostic Direction
iii
TUBULAR BELLS
Medicine is so very humbling. Stay on the key note. A striking
sign or subtle prompting must ring a bell to arouse or awaken
our curiosity. Each sounds its own message and beckons until
we respond to its real call. If you find a definite sign check its
etiology.
iv
APPROACH TO COMMON SIGNS
The ‘basicologists’ 33 The nephrologists 100
Jaundice 34 Renal failure 101
Bleeding 35 Red urine 104
Anemia 36 Renal anasarca 105
Clubbing 38 The pulmonologists 106
Central cyanosis 39
Crepitations 109
Oedema 40
Pneumonia 110
Lymphadenopathy 41
Pleural effusion 112
The haematologists 43 Lung Ca 113
Fever 44 A Wheeze 114
Hepatomegaly 49 COPD 116
Splenomegaly 51 Haemoptysis 119
HSM 53
The gastroenterologist 120
HSM + lymph nodes 54
Ascites 121
Sarcoid 55
Alcohol 123
Parotomegaly 56
Vomiting 124
Deep skin pigmentation 56
Diarrhoea 125
Cachexia 57
Constipation 126
The rheumatologists 59 Poisoning 127
Joint pain 60 The neurologists 129
Auto-immune disease SLE, RA 62
Disturbance of gait 130
Backache/ bone pain 64
Movement disorders 131
The cardiologists 66 Headache 133
Heart failure 68 Confusion 135
Hypertension 74 Seizures 135
A raised JVP 77 Weakness 136
Congenital heart disease 79 Stroke 137
Acute rheumatic fever 81 The endocrinologist 138
Infective endocarditis- Murmur 82
Obesity 139
Mitral stenosis 84
Diabetes mellitus 140
Aortic stenosis 86
Cushing’s 145
Mitral regurgitation 87
Thyroid diseases 146
Aortic incompetence 89
Pituitary presentation 148
Collapse 90
Gynaecomastia 149
Bradycardia 92
Hypercalcemia 150
Coma 93
Addison’s 150
Chest pain 95
Atrial fibrillation 96 The gerontologists 151
Shock + common emergencies 98
v
About the author and illustrator
Maria Ribeiro b.1954, in Durban, South Africa.
Maria specialized in Internal Medicine, followed by a sub-
specialty in Medical Oncology. She works as a consultant
physician at Kalafong Hospital and the University of Pretoria
where she trains senior medical students in Clinical Medicine.
Sound Diagnosis is illustrated by Gerard Hoffnung’s endearing
cartoons in which the author discovered remarkable
connections between the conductor trying to master
instruments of the orchestra and the numerous observations
that a doctor needs to make in order to reach a sound diagnosis.
Gerard Hoffnung b.1925, in Berlin, Germany.
Gerard arrived in London in 1939 as a schoolboy refugee. From
an early age, his gift of observation found natural expression in
capturing the elements of music inherent to life.
Gerard died of a cerebral haemorrhage in 1959. He leaves a
sweet legacy, a small taste of which you can find in this book.
vi
Acknowledgements
I came upon the art-work of Gerard Hoffnung in 2002 while
browsing in the bookshop of the Royal Festival Hall in London.
I am delighted to combine the strengths of artist and physician
to appreciate the music in medicine and to help you hear the
‘symphony’ when a problem comes to resolution. (It sounds
like …) Suddenly it all comes together to crescendo, just before
the diagnosis is made, into a naturally harmonized conclusion.
I would like to record here my sincere thanks to Annetta
Hoffnung, Gerard’s widow, for granting me permission to use
many of her husband’s timeless drawings to enhance my work,
and for being so instrumental in the whole project.
I thank my mother for lifelong encouragement, and my dear
husband and children for their forbearance during the writing
of this book.
I am deeply grateful to all students, patients and colleagues
who have helped me clarify diagnosis first-hand. Dr. Jurgen
Dinkel and Professor James Ker of the University of Pretoria
have given very generously of their time and advice toward
helping me consolidate pathology in medicine.
I am thankful for each person’s valued contribution, from the
book’s inception - Dr Hannah Brand, Gerard B, Doris, Peggy -
through to final design - Vera Brice - and Radcliffe publication.
Maria Mendes Ribeiro
August 2007
vii
KEY SIGNATURE
Employ the systematic approach to clarify diagnosis!
viii
1 AN OVERVIEW OF
WHAT LIES AHEAD
Constructing a sound diagnosis
As good practitioners of medicine,
we facilitate the process of diagnosis
by respecting its systematic flow.
Be patient. Listen and be aware.
Conduct your diagnosis with flair –
in three flowing systematic movements:
(cid:104) the 1st is OBSERVATION
(cid:104) the 2nd is EXPLORATION and
(cid:104) the 3rd is INTEGRATION.
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