Table Of ContentThe Rational Clinical Examination
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The Rational Clinical Examination
Evidence-Based Clinical Diagnosis
Editors
David L. Simel, MD, MHS
Chief, Medicine Service
Durham Veterans Affairs Medical Center
Professor of Medicine
Duke University School of Medicine
Durham, North Carolina
Drummond Rennie, MD
JAMA
Chicago, Illinois
Philip R. Lee Institute for Health Policy Studies
University of California, San Francisco
San Francisco, California
Editor, Education Guides
Sheri A. Keitz, MD, PhD
Chief, Medicine Service
Miami Veterans Affairs Medical Center
Associate Dean for Faculty Diversity and Development
University of Miami Miller School of Medicine
Miami, Florida
New York Chicago San Francisco Lisbon London
Madrid Mexico City Milan New Delhi San Juan
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CONTENTS
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvii
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
1. A Primer on the Precision and Accuracy of the Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
UPDATE: Primer on Precision and Accuracy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
2. Does This Patient Have Abdominal Aortic Aneurysm?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
UPDATE: Abdominal Aortic Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
3. Is Listening for Abdominal Bruits Useful in the Evaluation of Hypertension? . . . . . . . . . . . . . . . . . . . . . . . . . . .29
UPDATE: Abdominal Bruits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
4. Does This Patient Have an Alcohol Problem?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
UPDATE: Problem Alcohol Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
5. Does This Adult Patient Have Appendicitis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
UPDATE: Appendicitis, Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61
6. Does This Patient Have Ascites?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
UPDATE: Ascites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71
7. What Can the Medical History and Physical Examination Tell Us About Low Back Pain? . . . . . . . . . . . . . . . . . .75
UPDATE: Low Back Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83
8. Does This Patient Have Breast Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87
UPDATE: Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
9. Does This Patient Have a Clinically Important Carotid Bruit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
UPDATE: Carotid Bruit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
10. Does This Patient Have Carpal Tunnel Syndrome? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111
UPDATE: Carpal Tunnel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
11. Does This Patient Have Abnormal Central Venous Pressure?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125
UPDATE: Central Venous Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
12. Does This Patient Have Acute Cholecystitis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
UPDATE: Cholecystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
13. Does the Clinical Examination Predict Airflow Limitation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149
UPDATE: Chronic Obstructive Airways Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159
14. Does This Patient Have Clubbing?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163
UPDATE: Clubbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .171
15. Is This Patient Taking the Treatment as Prescribed?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173
UPDATE: Compliance and Medication Adherence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179
16(A). Can the Clinical Examination Diagnose Left-Sided Heart Failure in Adults?. . . . . . . . . . . . . . . . . . . . . . . . . . .183
v
Contents
16(B). Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? . . . . . . . . . . . . . . .195
UPDATE: Congestive Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209
17. Is This Patient Dead, Vegetative, or Severely Neurologically Impaired? Assessing Outcome
for Comatose Survivors of Cardiac Arrest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215
UPDATE: Death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225
18(A). Does This Patient Have Deep Vein Thrombosis? (1998). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .227
18(B). Does This Patient Have Deep Vein Thrombosis? (2006). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235
UPDATE: Deep Vein Thrombosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .245
19. Is This Patient Clinically Depressed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .247
UPDATE: Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .259
20. Does This Patient Have a Family History of Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265
UPDATE: Family History of Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .275
21. Does This Patient Have a Goiter?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277
UPDATE: Goiter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .285
22. Does This Patient Have Hepatomegaly? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .289
UPDATE: Hepatomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .299
23. Does This Patient Have Hypertension? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .301
UPDATE: Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .311
24. Is This Adult Patient Hypovolemic?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .315
UPDATE: Hypovolemia, Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .325
25. Is This Child Dehydrated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329
UPDATE: Hypovolemia, Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .339
26. Does This Patient Have Influenza?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .343
UPDATE: Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .355
27. Does This Patient Have a Torn Meniscus or Ligament of the Knee? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .357
UPDATE: Knee Ligaments and Menisci. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .369
28. Is This Adult Patient Malnourished? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .371
UPDATE: Malnourishment, Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .379
29. Does This Patient Have a Mole or a Melanoma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .383
UPDATE: Melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .391
30. Does This Adult Patient Have Acute Meningitis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .395
UPDATE: Meningitis, Adult. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .403
31. Is This Woman Perimenopausal?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .407
UPDATE: Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .415
32. Does This Patient Have Aortic Regurgitation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .419
UPDATE: Murmur, Diastolic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .429
33. Does This Patient Have an Abnormal Systolic Murmur?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .433
UPDATE: Murmur, Systolic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .443
34. Does This Patient Have Myasthenia Gravis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .449
UPDATE: Myasthenia Gravis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .459
vi
Contents
35. Is This Patient Having a Myocardial Infarction?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .461
UPDATE: Myocardial Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .471
36. Does This Woman Have Osteoporosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .477
UPDATE: Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .489
37. Does This Child Have Acute Otitis Media? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .493
UPDATE: Otitis Media, Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .501
38. Does This Patient Have Parkinson Disease?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .505
UPDATE: Parkinsonism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .513
39. Is This Patient Allergic to Penicillin? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .515
UPDATE: Penicillin Allergy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .523
40. Does This Adult Patient Have Community-Acquired Pneumonia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .527
UPDATE: Community-Acquired Pneumonia, Adult. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .535
41. Does This Infant Have Pneumonia?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .539
UPDATE: Pneumonia, Infant and Child. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .547
42. Is This Patient Pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .551
UPDATE: Early Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .559
43. Does This Patient Have Pulmonary Embolism?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .561
UPDATE: Pulmonary Embolus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .571
44. Does This Patient Have an Instability of the Shoulder or a Labrum Lesion? . . . . . . . . . . . . . . . . . . . . . . . . . .577
UPDATE: Shoulder Instability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .589
45. Does This Patient Have Sinusitis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .593
UPDATE: Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .601
46. Does This Patient Have Splenomegaly?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .605
UPDATE: Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .611
47. Does This Patient Have Strep Throat? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .615
UPDATE: Streptococcal Pharyngitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .623
48. Is This Patient Having a Stroke? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .627
UPDATE: Stroke. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .641
49. Does This Patient Have Temporal Arteritis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .643
UPDATE: Temporal Arteritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .653
50. Does This Patient Have an Acute Thoracic Aortic Dissection? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .659
UPDATE: Thoracic Aortic Dissection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .671
51. Does This Woman Have an Acute Uncomplicated Urinary Tract Infection? . . . . . . . . . . . . . . . . . . . . . . . . . . .675
UPDATE: Urinary Tract Infection, Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .687
52. What Is Causing This Patient’s Vaginal Symptoms? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .691
UPDATE: Vaginitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .705
53. Does This Dizzy Patient Have a Serious Form of Vertigo? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .709
UPDATE: Vertigo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .715
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .719
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JAMAevidence: Using Evidence to Improve Care
Founded around the Users’ Guides to the Medical Literature and The Rational Clinical Examina-
tion: Evidence-Based Clinical Diagnosis, JAMAevidence offers an invaluable online resource for
learning, teaching, and practicing evidence-based medicine (EBM). Updated regularly, the site
includes fully searchable content of the Users’ Guides to the Medical Literature and The Rational
Clinical Examination and features podcasts from the leading minds in EBM, interactive work-
sheets, question wizards, functional calculators, and a comprehensive collection of PowerPoint
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