Macleod's Clinical Examination

Cover image
	Title page
John Macleod (1915–2006)
Macleod’s: Clinical Examination
Copyright
	Table of Contents
Preface
Acknowledgements
How to make the most of this book and associated multimedia
	Examination sequences
Clinical examination videos
	Outline placeholder
		Key points in examinations: photo galleries
		Video contents
Contributors
1. Managing clinical encounters with patients
	The clinical encounter
		Reasons for the encounter
		The clinical environment
		Opening the encounter
		Gathering information
		Handling sensitive information and third parties
		Managing patient concerns
		Showing empathy
		Showing cultural sensitivity
		Addressing the problem
		Concluding the encounter
	Professional responsibilities
		Confidentiality and consent
		Social media
	Personal responsibilities
2. General aspects of history taking
	The importance of a clear history
	Gathering information
		Beginning the history
			Preparation
				Allowing sufficient time
			Starting your consultation
				Using different styles of question
				Showing empathy when taking a history
		The history of the presenting symptoms
		Past medical history
		Drug history
			Non-prescribed drug use
			Concordance and adherence
			Drug allergies/reactions
		Family history
		Social history and lifestyle
			Smoking
			Alcohol
				Alcohol problems
			Occupational history
			Travel history
			Sexual history
		Systematic enquiry
		Closing the interview
	Difficult situations
		Patients with communication difficulties
			Interpreted consultation
			Hearing or speech difficulties
		Patients with cognitive difficulties
		Sensitive situations
		Emotional or angry patients
3. General aspects of examination
	General principles of physical examination
	Preparing for physical examination
	Sequence for performing a physical examination
	Initial observations
		Gait and posture
		Facial expression and speech
	Hands
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			Deformity
			Colour
			Temperature
			Skin
			Nails
	Skin
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			Haemochromatosis
			Haemosiderin
			Easy bruising
			Hypercarotenaemia
			Discolouration
				Jaundice
				Pallor
				Cyanosis
					Central cyanosis
					Peripheral cyanosis
			Characteristic skin changes
	Tongue
	Odours
	Body habitus and nutrition
		Weight
			Obesity
			Weight loss
		Stature
			Short stature
			Tall stature
		Hydration (Video 1)
			Localised oedema
				Venous causes
				Lymphatic causes
				Inflammatory causes
				Allergic causes
	Lumps and lymph nodes
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			Lumps
				Size
				Position
				Attachment
				Consistency
				Edge
				Surface and shape
				Pulsations, thrills and bruits
				Inflammation
				Transillumination
			Lymph nodes
	Spot diagnoses
		Major chromosomal abnormalities
			Down’s syndrome (trisomy 21 – 47XX/XY + 21)
			Turner’s syndrome (45XO)
			Klinefelter’s syndrome (47XXY)
			Achondroplasia
4. The cardiovascular system
	Heart
	Anatomy and physiology
	The history
		Common presenting symptoms
			Chest pain
				Intermittent chest pain
				Acute chest pain
			Dyspnoea (breathlessness)
			Palpitation
			Syncope and presyncope
			Oedema
			Other symptoms of cardiac disease
		Past medical history
		Drug history
		Family history
		Social history
	The physical examination (Video 3)
		General examination
			Hands
			Face
		Arterial pulses
			Rate and rhythm
			Volume and character
		Blood pressure
			Hypertension
			Korotkoff sounds
			Common problems in blood pressure (bp) measurement
		Jugular venous pressure and waveform
		Precordium
			Inspection
			Palpation
			Auscultation
				Heart sounds
					First heart sound
					Second heart sound
					Third heart sound
					Fourth heart sound
					Additional sounds
				Prosthetic valve sounds
				Murmurs
					Systolic murmurs
					Diastolic murmurs
					Continuous murmurs
	Interpretation of the findings
	Investigations
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			Haematology and clinical chemistry
			Electrocardiography
				Ambulatory ECG monitoring
				Exercise ECG
			Ambulatory blood pressure monitoring
			Chest X-ray
			Echocardiography
			Radionuclide studies
			Cardiac catheterisation
			Computed tomography and magnetic resonance imaging
	Peripheral arterial system
	Anatomy and physiology
	The history
		Common presenting symptoms
			Leg pain
				Asymptomatic ischaemia
				Intermittent claudication
				Night pain
				Rest pain
				Tissue loss (ulceration and/or gangrene)
				Tissue loss in the diabetic patient
				Acute limb ischaemia
				Compartment syndrome
			Abdominal pain
				Mesenteric ischaemia
				Abdominal aortic aneurysm
			Digital ischaemia
				Blue toes
				Vasospastic symptoms
			Stroke
		Past medical history
		Drug history
		Family history
		Social history
	The physical examination
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			Buerger’s test
			Ankle: brachial pressure index
	Investigations
	Peripheral venous system
	Anatomy and physiology
	The history
		Common presenting symptoms
			Pain
			Limb swelling
			Skin changes
				Chronic venous ulceration
			Superficial venous thrombophlebitis
		Past history
	The physical examination
	Investigations
5. The respiratory system
	Anatomy and physiology
	The history
		Common presenting symptoms
			Breathlessness
			Wheeze
			Cough
			Sputum
				Colour
				Volume
				Consistency
			Haemoptysis
			Stridor
			Chest pain
			Fevers/rigors/night sweats
			Weight loss
			Sleepiness
		Past medical history
		Drug and allergy history
		Family history
		Social history
			Smoking
			Occupational history
		Systematic enquiry
	The physical examination
		Inspection
			Hands and arms
			Face
			Neck
			Thorax
		Palpation
		Percussion
		Auscultation
			Use of the stethoscope
				Breath sounds
				Added sounds
				Vocal resonance
	Interpretation of the findings
	Investigations
6. The gastrointestinal system
	Anatomy and physiology
	The history
		Common presenting symptoms
			Mouth symptoms
			Anorexia and weight loss
			Pain
				Painful mouth
				Heartburn and reflux
				Dyspepsia
				Odynophagia
				Abdominal pain
					Site
					Onset
					Character
					Radiation
					Associated symptoms
					Timing
					Exacerbating and relieving factors
					Severity
					The acute abdomen
			Dysphagia
			Nausea and vomiting
			Wind and flatulence
			Abdominal distension
			Altered bowel habit
				Diarrhoea
				Constipation
			Bleeding
				Haematemesis
				Melaena
				Rectal bleeding
			Jaundice
				Prehepatic jaundice
				Hepatic jaundice
				Posthepatic/cholestatic jaundice
			Groin swellings and lumps
		Past medical history
		Drug history
		Family history
		Social history
	The physical examination
		General examination
			Liver disease
		Abdominal examination
			Inspection
				Skin
				Visible veins
				Abdominal swelling
				Abdominal scars and stomas
			Palpation
				Tenderness
				Palpable mass
				Enlarged organs
				Hepatomegaly
			Percussion
				Splenomegaly
				Ascites
			Auscultation
		Hernias
		Rectal examination
		Proctoscopy
	Investigations
7. The nervous system
	Anatomy and physiology
	The history
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			Time relationships
			Precipitating, exacerbating or relieving factors
			Associated symptoms
		Common presenting symptoms
			Headache
			Transient loss of consciousness (TLOC)
			Seizure
			Focal neurological symptoms due to stroke or transient ischaemic attack
			Dizziness and vertigo
			Functional neurological symptoms
		Past medical history
		Drug history
		Family history
		Social history
			Occupational history
	The physical examination
		Assessment of conscious level
		Meningeal irritation
		Speech
		Dysphasia
			Anatomy
		Cortical function
			Frontal lobe
			Temporal lobe
			Parietal lobe
			Occipital lobe
	Cranial nerves
		Olfactory (I) nerve
			Anatomy
		Optic (II), oculomotor (III), trochlear (IV) and abducens (VI) nerves
		Trigeminal (V) nerve
			Anatomy
		Facial (VII) nerve
			Anatomy
		The vestibulocochlear (VIII) nerve
		Glossopharyngeal (IX) and vagus (X) nerves
			Anatomy
		Accessory (XI) nerve
			Anatomy
		Hypoglossal (XII) nerve
			Anatomy
	Motor system (Videos 12 and 13)
		Anatomy
			Upper motor neuron lesions
			Lower motor neuron lesions
			Basal ganglia lesions
		Stance and gait
		Inspection and palpation of the muscles
			Muscle bulk
			Fasciculation
			Abnormal movements
				Myoclonic jerks
				Tremor
				Other involuntary movements
		Tone
			Hypotonia
			Hypertonia
			Clonus
			Myotonia
		Power
		Deep tendon reflexes
			Anatomy
		Primitive reflexes
		Coordination
			Anatomy
			Apraxia
	Sensory system
		Anatomy
		Common presenting symptoms
		Sensory modalities
			Peripheral nerve and dorsal root
			Spinal cord
			Intracranial lesions
	Peripheral nerves (Video 16)
		Median nerve
		Radial nerve
		Ulnar nerve
		Common peroneal nerve
		Lateral cutaneous nerve of the thigh
	Interpretation of the findings
	Investigations
		Initial investigations
		Specific investigations
			Lumbar puncture
			Neurophysiological tests
8. The visual system
	Anatomy and physiology
		Eye
		Extraocular muscles
		Refractive elements of the eye
		Visual pathway
		Pupillary pathways
	Patient history
		Common presenting symptoms
			Change in vision
			Pain
			Red eye
			Double vision (diplopia)
			Discharge
			Swollen eyes
		Past ocular history
		Past medical history
		Drug and allergy history
		Family history
		Social history
	The physical examination (Video 17)
		General examination
		Visual acuity
		Orbit and periorbital examination
		Pupils (Video 17C)
			Anisocoria
			Direct and consensual light reflex
			Relative afferent pupillary defect
			Accommodation
			Horner\'s syndrome
			Adie’s pupil
			Argyll Robertson pupil
		Visual fields
		Ocular alignment and eye movements
			Detection of a squint
			Ocular movements
			Oculocephalic (doll’s-eye) reflex
			Nystagmus
		Ophthalmoscopy
		Retinopathies
	Investigations
	Ophthalmic examination and COVID-19
9. The ear, nose and throat: Nose and sinuses
	Ear
	Anatomy and physiology
		External ear
		Middle ear
		Inner ear
	The history
		Common presenting symptoms
			Pain and itching
			Ear discharge
			Hearing loss
			Tinnitus
			Vertigo
			Nystagmus
		Past medical history
		Drug history
		Family history
		Social history
	The physical examination
		Testing hearing (Video 19)
			Whispered voice test
			Tuning fork tests
				Weber’s test
				Rinne’s test
		Testing vestibular function
			Testing for nystagmus
			Dix–Hallpike positional test
			Head impulse test (or head thrust test)
			Unterberger’s test
			Fistula test
	Investigations
	Nose and sinuses
	Anatomy and physiology
	The history
		Common presenting symptoms
			Nasal obstruction
			Nasal discharge
			Epistaxis (bleeding from inside the nose)
			Sneezing
			Disturbance of smell
			Nasal and facial pain
			Nasal deformity
		Past medical history
		Drug history
		Family history
		Social history
	The physical examination
	Investigations
	Mouth, throat and neck
	Anatomy and physiology
		Mouth
		Throat
		Teeth
		Neck
	The history
		Common presenting symptoms
			Sore mouth
			Sore throat
			Stridor
			Dysphonia
			Dysphagia
			Neck lump
		Past medical history
		Drug history
		Social and family history
	The physical examination
		Mouth and throat
		Neck
	Investigations
10. The endocrine system
	The thyroid
	Anatomy and physiology
	The history
		Common presenting symptoms
			Neck swelling
			Neck pain
			History suggesting hyperthyroidism
			History suggesting hypothyroidism
		Past medical, drug, family and social history
	The physical examination
		General examination
		Thyroid gland
		Eyes
	The parathyroids
	Anatomy and physiology
	The history
		Common presenting symptoms
		Past medical, drug, family and social history
	The physical examination
	The pituitary
	Anatomy and physiology
	The history
		Common presenting symptoms
			Prolactinoma
			Acromegaly
			Hypopituitarism
		Family history
	The physical examination
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			Acromegaly
			Hypopituitarism
	The adrenals
	Anatomy and physiology
	The history
		Common presenting symptoms
			Adrenal insufficiency
			Cushing\'s syndrome
		Past medical and drug history
	The physical examination
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			Adrenal insufficiency
			Cushing\'s syndrome
	The gonads
	Anatomy and physiology
		Common presenting symptoms and signs
	Diabetes
	Anatomy and physiology
	The history
		Common presenting symptoms
			Newly diagnosed diabetes mellitus
			Diabetic ketoacidosis
			Hypoglycaemia
		Past medical, drug, family and social history
	The physical examination
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			Assessment of a person with newly diagnosed diabetes
			Routine review of a person with diabetes
			The diabetic foot
11. The reproductive system
	Breast
	Anatomy and physiology
	The history
		Common presenting symptoms
			Breast pain (mastalgia)
			Breast lump
			Breast volume and shape changes
			Skin changes
			Nipple changes
			Gynaecomastia
	The physical examination
	Investigations
	Female reproductive system
	Anatomy and physiology
	The history
		Common presenting symptoms
			Abnormal vaginal bleeding
			Lower abdominal pain
			Abdominal distension and bloating
			Vaginal discharge
			Urinary incontinence
			Prolapse
		Drug history
		Family and social history
		Sexual history
	The physical examination
		Passing a speculum
		Taking a cervical smear
		Bimanual examination
	Investigations
	Obstetric history and examination: the booking visit
	The history
		Past medical history
		Drug history
		Family history
		Social history
			Occupational history
	Investigations
	Routine antenatal check in later pregnancy
	The history
		Common presenting symptoms
			Physiological symptoms
			Reduced fetal movements
			Vaginal bleeding in pregnancy
			Abdominal pain
			Pre-eclampsia
			Pruritus
			Breathlessness
	The physical examination
	Investigations
	Male reproductive system
	Anatomy and physiology
	The history
		Common presenting symptoms
			Urinary symptoms
			Penile discharge or dysuria
			Scrotal swelling or pain
			Penile skin lesions
			Erectile dysfunction
		Past medical history
		Drug history
		Social history
	The physical examination
		Skin
		Penis
		Scrotum
			Varicocoele
			Hydrocoele
			Epididymal cyst
			Testicular tumour
			Epididymitis
			Testicular torsion
			Single testis
			Bilateral testicular atrophy
		Prostate
	Investigations
12. The renal system
	Anatomy and physiology
	The history
		Common presenting symptoms
			Dysuria
			Loin pain
			Voiding symptoms
			Hematuria
				Visible haematuria
				Non-visible haematuria
			Proteinuria and nephrotic syndrome
			Acute kidney injury
				Prerenal acute kidney injury
				Intrinsic acute kidney injury
				Postrenal acute kidney injury
			Chronic kidney disease
			Kidney failure and uraemia
			The patient with a renal transplant
			The dialysis patient
			Other presenting symptoms
		Past medical history
		Drug history
		Family history
		Social history
	The physical examination
		General appearance
			Hands
			Dialysis access
			Face
			Skin
		Assessment of fluid balance
			General appearance
			Pulse and blood pressure
			Jugular venous pressure
			Examination of the chest
			Peripheral oedema
			Weight
			Fluid balance charts
		Abdominal examination
		Targeted examination of other systems
			Joints
			Nervous system
			Prostate
	Interpretation of the findings
	Investigations
		Urinalysis
		Investigation of renal function
13. The musculoskeletal system
	The history
		Common presenting symptoms
			Pain
				Site
				Onset
				Character
				Radiation
				Associated symptoms
				Timing (frequency, duration and periodicity of symptoms)
				Exacerbating/relieving factors
				Severity
				Patterns of joint involvement
			Stiffness
			Swelling
			Erythema and warmth
			Weakness
			Locking and triggering
			Extra-articular symptoms
		Past medical history
		Drug history
		Family history
		Social history
	The physical examination
		General principles
			Look – feel – move
		General examination
			Skin, nail and soft tissues
				Nodules
			Eyes
			General features
			Joints: the GALS screen
				Initial questions
				Hypermobility
	Detailed examination of the musculoskeletal system
		Gait
			Pain
			Structural change
			Weakness
			Increased tone
		Spine
			Definitions
			Cervical spine
				Anatomy and physiology
				The history
				The physical examination
			Thoracic spine
				Anatomy and physiology
				The history
				The physical examination
			Lumbar spine
				Anatomy and physiology
				The history
				The physical examination
				Special tests
					Schober’s test for forward flexion
					Root compression tests
					Sciatic nerve stretch test (L4–S1)
					Femoral nerve stretch test (L2–4)
					Flip test for functional overlay
			Sacroiliac joints
		Upper limb
			Hand and wrist
				The history
				The physical examination
				Examining the wrist and hand with a wound
			Elbow
				Anatomy and physiology
				The physical examination
				Special tests
					Tennis elbow (lateral epicondylitis)
					Golfer’s elbow (medial epicondylitis)
			Shoulder
				Anatomy and physiology
				The history
				The physical examination
				Special tests for impingement
					Neer test
					Hawkins–Kennedy test (Fig. 13.32)
		Lower limb
			Hip
				Anatomy
				The history
				The physical examination
				Special tests
					Shortening
					Trendelenburg’s sign
			Knee
				Anatomy
				The history
					Pain
					Swelling
					Locking
					Instability (‘giving way’)
				The physical examination
				Ligament testing
					Collateral ligament
					Anterior cruciate ligament
				Tests for meniscal tears
					Meniscal provocation test (McMurray test)
					Patella
			Ankle and foot
				Anatomy
				The history
					Non-traumatic conditions
				The physical examination
				Special tests
					Achilles tendon
					Thomson’s (Simmond’s) test
					Mulder’s sign for Morton’s neuroma
	Fractures, dislocations and trauma
		The history
		The physical examination
	Investigations
14. The skin, hair and nails
	Anatomy and physiology
		Skin
		Hair
		Nails
	The history
		Common presenting symptoms
		Past medical and drug history
		Family and social history
	The physical examination
		Distribution of a rash
		Morphology of a rash
		Colour
		Specific features
		Morphology of lesions
		Mouth, hair and nail signs
		Supplementary examination techniques
			Dermatoscopy
			Diascopy
			Wood’s lamp
	Investigations
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			Skin biopsy
			Mycology
			Patch testing
15. Babies and Children
	Babies
	The history
		Maternal history
		Pregnancy history
		Birth history
		Infant’s progress
		Presenting problems and definitions
			Pallor
			Respiratory distress
			Cyanosis
			Acrocyanosis
			Jaundice
			Jitteriness
			Dysmorphism
			Hypotonia
			Apgar score
	The physical examination of newborns
		Timing and efficacy of the routine neonatal examination
		General examination
			Skin
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					Normal findings
					Abnormal findings
			Head
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					Normal findings
					Abnormal findings
			Eyes
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					Normal findings
					Abnormal findings
				Ophthalmoscopy
					Normal findings
					Abnormal findings
			Nose
			Mouth
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					Normal findings
					Abnormal findings
			Ears
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					Normal findings
					Abnormal findings
			Neck
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					Normal findings
					Abnormal findings
		Cardiovascular examination
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					Normal findings
					Abnormal findings
		Respiratory examination
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					Normal findings
					Abnormal findings
		Abdominal examination
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					Normal findings
					Abnormal findings
			Perineum
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					Normal findings
					Abnormal findings
			Spine and sacrum
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					Normal findings
					Abnormal findings
		Neurological examination
			General neurological assessment
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					Normal findings
					Abnormal findings
			Primitive reflexes in newborn and young infants
		Limbs
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					Normal findings
					Abnormal findings
		Weighing and measuring
		Final inspection
	The physical examination of infants beyond the newborn period
	Older children
	The history
		Obtaining a history from children and young people compared with adults
		Common presenting symptoms
		Past medical history
		Birth history
		Vaccination history
		Developmental history
		Drug history
		Family and social history
		Systematic enquiry
	The physical examination
		Normal growth and development
			Growth
			Neurodevelopmental maturation
				The preschool child (1 to 5 years)
				The school-age child (5+ years)
				Puberty
		Physical examination techniques in children and young people
			Similarities in examination between children and young people and adults
			Differences in examination between children and young people and adults
				1 to 3 years
				3 to 5 years
				5+ years
		The acutely unwell children and young people
		General examination
			Height
			Vital signs
		Ears, nose and throat
			The preschool child
				Throat
					Abnormal findings
				Ears
				Lymphadenopathy
					Normal findings
		Cardiovascular examination
		Respiratory examination
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					Abnormal findings
		Abdominal examination
		Neurological examination
		Spotting the sick children and young people
	Child protection
	Remote consultation in paediatric practice
16. Patients with mental illness and learning disability
	The history
		General approach
		Sensitive topics
		The uncooperative patient
	The mental state examination
		Appearance
		Behaviour
		Speech
		Mood
		Thought form
		Thought content
			Preoccupations
			Ruminations
			Abnormal beliefs
			Overvalued ideas
			Delusional beliefs
		Perceptions
		Cognition
			Level of consciousness
			Orientation
			Memory
			Impaired attention and concentration
			Intelligence
		Insight
		Risk assessment
		Capacity
	The physical examination
	Collateral history
	Psychiatric rating scales
	Putting it all together: clinical vignettes
17. The frail patient
	The frail patient
	Assessment of the frail patient
		Factors influencing presentation and history
			Communication difficulties, cognition and mood
	The history
		The presenting symptoms
		Common presenting symptoms
			Decreased mobility
			Confusion
			Falls
		Past medical history
		Drug history
		Family history
		Social and functional history
		Systematic enquiry
	The physical examination
		General examination
			Hydration and nutrition
			The skin
			Pain behaviour
			Vision and hearing
		Systems examination
			Cardiovascular examination
			Respiratory examination
			Gastrointestinal examination
			Neurological examination
			Musculoskeletal examination
		Functional assessment (Video 32)
	Interpretation of the findings
18. The deteriorating patient
	Vital signs
	Early warning scores
	Initial assessment
	The ABCDE approach
		A: Airway
		B: Breathing
		C: Circulation
		D: Disability
		E: Exposure
	Point of care ultrasound
	Sepsis
	Ongoing management
19. The dying patient
	Assessing a dying patient
		Physiology
		The history
			Background information
			Establishing the broader context
		The physical examination
		Care in the last days of life
		Communication with patients and families
	Verifying and certifying death
		The history
		The physical examination
			Diagnosing death using neurological criteria
		Communication with families
		Medical certification of death
	Looking after yourself and others
20. Reaching and communicating a diagnosis
	Reaching a diagnosis
		Pretest probability
		Rare diseases
		Multimorbidity
		Diagnostic error
	Biopsychosocial model
	Approach to the patient with medically unexplained symptoms
	Communicating a diagnosis
	Shared decision-making
	Diagnostic and therapeutic uncertainty
	Documenting your findings
	Communicating with colleagues
		Verbal communication
			Using situation, background, assessment, recommendation
		Written communication
21. Adapting skills for practice
	Adapting to different presentations
		Presentation in emergency
		Presentation with localised illness
		Presentation with non-specific symptoms
	Adapting to different working environments
		Assessing patients in the community
		Remote consultation
			Telephone consultation
			Video consultation
			Examination and investigation
			Communicating with patients by message
	Adapting clinical skills over a career
22. Preparing for assessment
	General principles
	Methods of assessment
		Clinical simulation
		OSCEs
	Marking structures
	Approach to preparation
	Approach to assessment
		Professionalism
		Managing time
		Communication during assessment
		Managing unexpected difficulties
	Putting it all together
Index