Talley and O’Connor’s Clinical Examination (8th edition)

992 Pages·2017·99.29 MB·English

by  Nicholas J Talley

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2015v1.0
clinical
examination
A systematic guide to physical diagnosis
8th edition
VOLUME ONE
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clinical
examination
A systematic guide to physical diagnosis
8th edition
VOLUME ONE
NICHOLAS J TALLEY
MBBS (Hons)(NSW), MD (NSW), PhD (Syd), MMedSci (Clin Epi)(Newc.),
FRACP, FAFPHM, FAHMS, FRCP (Lond. & Edin.), FACP, FACG, AGAF, FAMS, FRCPI (Hon)
Laureate Professor and Pro Vice-Chancellor, Global Research, University of Newcastle, NSW, Australia
Senior Staff Specialist, John Hunter Hospital, Newcastle, NSW, Australia
Professor of Medicine, Professor of Epidemiology, Joint Supplemental Consultant Gastroenterology
and Health Sciences Research, Mayo Clinic, Rochester, MN, United States; Professor of Medicine,
University of North Carolina, United States; Foreign Guest Professor, Karolinska Institute, Sweden; Past
President, Royal Australasian College of Physicians
SIMON O’CONNOR
FRACP, DDU, FCSANZ
Cardiologist, The Canberra Hospital, Canberra, ACT, Australia
Clinical Senior Lecturer, Australian National University Medical School, Canberra, ACT, Australia
Elsevier Australia. ACN 001 002 357
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National Library of Australia Cataloging-in-Publication Data
Talley, Nicholas Joseph, author.
Clinical examination. Volume 1 : a systematic guide to
physical diagnosis / Nicholas J. Talley
& Simon O’Connor.
Eight edition.
9780729542869 (paperback)
Includes index.
Physical diagnosis.
O’Connor, Simon, author.
Senior Content Strategist: Larissa Norrie
Content Development Specialist: Lauren Santos
Project Manager: Devendran Kannan
Edited by Chris Wyard
Proofread by Annabel Adair
Design by Natalie Bowra
Index by Innodata Indexing
Typeset by Toppan BestSet Premedia Ltd.
Printed in China
Foreword
Clinical medicine is at its finest when demonstrated practice but, failing that, Talley and O’Connor were
by the best exponents of the clinical examination. Like extraordinarily helpful to me.
most doctors I could name five or so of my teachers It was only in recent years that I met one of the
and colleagues who made the clinical examination both authors, Nick Talley, and I greeted him with almost
a true art and finely honed diagnostic tool. They have the same gratitude that a Harry Potter fan would greet
had my enduring admiration and respect. J.K. Rowling. It fazed him not one iota. I suspect that
In the interests of open disclosure, and in order to he, and Simon O’Connor who, unfortunately, I have
protect the integrity of Nick Talley and Simon O’Connor, not met in spite of my spending five years in Canberra,
I am obliged to point out that I never perfected the are well used to such a reaction from the doctors they
art of a smooth, seamless, comprehensive physical have assisted for the past 30 years.
examination. This 8th edition of Clinical Examination has updated,
I’m sure examiners could see me, and almost hear peer-reviewed text with recent evidence, new images,
me, thinking through the cranial nerve examination clinical hints and guidance for OSCE.
nerve by nerve in much the same way that a novice The writing is clear. The richness and the potential
dancer counts out loud the requisite steps while of an understanding of a patient gained through the
progressing through an uncomplicated routine. clinical examination shines through. The text encourages
I read, digested, wrote on and tried to memorise the the reader to think logically about their approach and
other Talley and O’Connor text Examination Medicine, it does not impose a rote learning style. Nevertheless
which was first published in 1985 and which I used there are many aids throughout to encourage retention
for my clinical examination for my Fellowship in of what has been learned. Summary chapters, diagrams,
Emergency Medicine. tables, mnemonics, tips and tests will assist a quick
The first edition of this book, Clinical Examination, revision.
was published in 1988 and is aimed particularly at Given my own interest in the art of medicine over
medical students. Perhaps if they had written this book the years, I found the chapter on clinical methods: an
a decade earlier when I was a student, as were they, I historical perspective, illuminating, grounding and
might have been more accomplished. reassuring. The art of the clinical examination is timeless
Of course a book alone, however well written, cannot and has not been forgotten by these authors.
confer proficiency in the art of history taking and
physical examination. Only repeated practice, built on Professor Chris Baggoley AO, BVSc(Hons), BM BS,
logical construction in the art, can achieve that. I suspect BSocAdmin, FACEM, FRACMA, D.Univ (Flin)
I could have done much better in my attitude to diligent EDMS, Southern Adelaide Local Health Network
Contents
Foreword v Mood 19
Preface xix Sexual history 19
Acknowledgements xx Family history 19
Clinical methods: an historical perspective xxii Systems review 19
The Hippocratic oath xxiv Skills in history taking 20
T&O’C essentials 20
VOLUME ONE References 21
CHAPTER 2
SECTION 1
Advanced history taking 22
THE GENERAL PRINCIPLES OF HISTORY
Taking a good history 22
TAKING AND PHYSICAL EXAMINATION 1
The differential diagnosis 22
CHAPTER 1 Fundamental considerations when taking
The general principles of history taking 3
the history 22
T&O’C essentials 3 Personal history taking 23
Bedside manner and establishing rapport 3 Common general symptoms 24
Obtaining the history 5 Sexual history 27
Introductory questions 6 Reproductive history 27
T&O’C essentials 6 Cross-cultural history taking 28
Presenting (principal) symptom 7 The ‘uncooperative’ or ‘difficult’ patient 28
History of the presenting illness 7 Self-harming and Münchhausen’s syndrome 29
Current symptoms 7 History taking for the maintenance of good
Associated symptoms 8 health 29
The effect of the illness 12 The elderly patient 31
Drug and treatment history 12 Activities of daily living 31
Past history 14 Polypharmacy 32
Additional history for the female patient 15 Adherence 32
Social history 15 Mental state 32
T&O’C essentials 15 Specific problems in the elderly 33
Upbringing and education level 15 Advance care planning (advance health
Marital status, social support and living directives) 33
conditions 15 Patient confidentiality 33
Diet and exercise 16 Evidence-based history taking and
Occupation and hobbies 16 differential diagnosis 33
Overseas travel 16 The clinical assessment 34
Smoking 16 Concluding the consultation 34
Alcohol use 17 T&O’C essentials 35
Analgesics and street drugs 18 References 35
Contents vii
CHAPTER 3 CHAPTER 5
The general principles of physical The cardiac examination 74
examination 37
Examination anatomy 74
Clinical examination 38 Positioning the patient 75
How to start 38 General appearance 76
Hand washing 38 Hands 79
First impressions 39 Arterial pulse 81
Vital signs 40 Rate of pulse 83
Facies 40 Rhythm 83
Jaundice 40 Radiofemoral and radial–radial delay 83
Cyanosis 41 Character and volume 84
Pallor 44 Condition of the vessel wall 84
Hair 45 Blood pressure 84
Weight, body habitus and posture 45 Measuring the blood pressure with the
Hydration 46 sphygmomanometer 86
The hands and nails 48 Variations in blood pressure 88
Temperature 49 High blood pressure 88
Smell 50 Postural blood pressure 88
Preparing the patient for examination 51 Face 89
Advanced concepts: evidence-based Neck 89
clinical examination 51 Carotid arteries 89
Inter-observer agreement (reliability) and Jugular venous pressure 90
the κ-statistic 53 Praecordium 92
T&O’C essentials 54 Inspection 92
Introduction to the OSCE 55 Palpation 93
References 56 Percussion 95
Auscultation 95
Abnormalities of the heart sounds 97
SECTION 2 Murmurs of the heart 100
THE CARDIOVASCULAR SYSTEM 57 Auscultation of the neck 105
The back 106
CHAPTER 4
The abdomen and legs 106
The cardiovascular history 59
T&O’C essentials 107
Presenting symptoms 59
OSCE example – CVS examination 107
Chest pain 59
OSCE revision topics – CVS examination 108
Dyspnoea 63
References 108
Ankle swelling 64
Palpitations 64 CHAPTER 6
The limb examination and peripheral
Syncope, presyncope and dizziness 66
vascular disease 109
Fatigue 67
Intermittent claudication and peripheral Examination anatomy 109
vascular disease 67 Arms 109
Risk factors for coronary artery Legs 109
disease 68 Lower limbs 109
Drug and treatment history 70 Peripheral vascular disease 113
Past history 70 Acute arterial occlusion 114
Social history 71 Deep venous thrombosis 115
Family history 71 Varicose veins 115
T&O’C essentials 71 Chronic venous disease 116
OSCE example – CVS history 72 T&O’C essentials 117
OSCE revision topics – CVS history 72 OSCE example – peripheral vascular
References 72 disease 117
viii Contents Contents ix
OSCE revision topics 118 Eisenmenger’s syndrome (pulmonary
References 118 hypertension and a right-to-left shunt) 142
Fallot’s syndrome 142
CHAPTER 7
‘Grown-up’ congenital heart disease 143
Correlation of physical signs
Fallot’s syndrome 143
disease and cardiovascular
Transposition of the great arteries 143
disease 119
T&O’C essentials 143
Cardiac failure 119 OSCE example – cardiovascular examination 144
Left ventricular failure (LVF) 119 OSCE revision topics – cardiovascular
Right ventricular failure (RVF) 120 examination 144
Chest pain 121 References 144
Myocardial infarction or acute coronary
CHAPTER 8
syndrome 121
A summary of the cardiovascular
Pulmonary embolism 122
examination and extending the
Acute aortic dissection 122
cardiovascular examination 145
Pericardial disease 122
Acute pericarditis 122 Extending the cardiovascular physical
Chronic constrictive pericarditis 123 examination 147
Acute cardiac tamponade 123 The chest X-ray: a systematic approach 147
Infective endocarditis 123 The echocardiogram 151
Systemic hypertension 124 T&O’C essentials 159
Causes of systemic hypertension 125 OSCE revision topics 159
Complications of hypertension 125
Malignant (accelerated) hypertension 125
SECTION 3
Pulmonary hypertension 125
THE RESPIRATORY SYSTEM 161
Causes of pulmonary hypertension 126
Innocent murmurs 126 CHAPTER 9
Valve diseases of the left heart 126 The respiratory history 163
Mitral stenosis 126
Presenting symptoms 163
Mitral regurgitation (chronic) 128
Cough and sputum 163
Acute mitral regurgitation 129
Haemoptysis 165
Mitral valve prolapse (MVP, systolic-click
Breathlessness (dyspnoea) 165
murmur syndrome) 130
Wheeze 168
Aortic stenosis (AS) 130
Chest pain 168
Aortic regurgitation 131
Other presenting symptoms 168
Valve diseases of the right heart 135
Current treatment 169
Tricuspid stenosis 135
Past history 171
Tricuspid regurgitation (TR) 136
Occupational history 171
Pulmonary stenosis (in adults) 137
Social history 172
Pulmonary regurgitation 137
Family history 173
Prosthetic heart valves 137
T&O’C essentials 173
Cardiomyopathy 137
OSCE revision topics – the respiratory
Hypertrophic cardiomyopathy 137
history 173
Dilated cardiomyopathy 139
References 173
Restrictive cardiomyopathy 139
Acyanotic congenital heart disease 139 CHAPTER 10
The respiratory examination 174
Ventricular septal defect 139
Atrial septal defect 139 Examination anatomy 174
Patent ductus arteriosus 141 Positioning the patient 174
Coarctation of the aorta 141 General appearance 174
Ebstein’s anomaly 141 Dyspnoea 174
Cyanotic congenital heart disease 142 Characteristic signs of COPD 175