Preface

Despite the wealth of diagnostic tools available to the modern

physician, the acquisition of information by direct interaction

with the patient through history taking and clinical examination

remains the bedrock of the physician’s art. These time-honoured

skills can often allow clinicians to reach a clear diagnosis without

recourse to expensive and potentially harmful tests.

This book aims to assist clinicians in developing the consultation

skills required to elicit a clear history, and the practical skills

needed to detect clinical signs of disease. Where possible, the

physical basis of clinical signs is explained to aid understanding.

Formulation of a differential diagnosis from the information gained

is introduced, and the logical initial investigations are included for

each system. Macleod’s Clinical Examination is designed to be

used in conjunction with more detailed texts on pathophysiology,

differential diagnosis and clinical medicine, illustrating specifically

how the history and examination can inform the diagnostic

process.

In this edition the contents have been restructured and the

text comprehensively updated by a team of existing and new

authors, with the aim of creating an accessible and user-friendly

text relevant to the practice of medicine in the 21st century.

Section 1 addresses the general principles of good interaction

with patients, from the basics of taking a history and examining,

to the use of pattern recognition to identify spot diagnoses.

Section 2 deals with symptoms and signs in specific systems

and Section 3 illustrates the application of these skills to specific

clinical situations. Section 4 covers preparation for assessments

of clinical skills and for the use of these skills in everyday practice.

An expertly performed history and examination of a patient

allows the doctor to detect disease and predict prognosis, and is

crucial to the principle of making the patient and their concerns

central to the care process, and also to the avoidance of harm

from unnecessary or unjustified tests.

We hope that if young clinicians are encouraged to adopt

and adapt these skills, they not only will serve their patients

as diagnosticians but also will themselves continue to develop

clinical examination techniques and a better understanding of

their mechanisms and diagnostic use.

The 14th edition of Macleod’s Clinical Examination has an

accompanying set of videos available in the online Student

Consult electronic library. This book is closely integrated with

Davidson’s Principles and Practice of Medicine and is best read

in conjunction with that text.

JAI, ARD, KF

Edinburgh, 2018

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Acknowledgements

The editors would like acknowledge the immense contribution

made by Graham Douglas, Fiona Nicol and Colin Robertson

who edited the three previous editions of Macleod’s Clinical

Examination. Together they re-shaped the format of this textbook

and their efforts were rewarded by a substantial growth in both

its sales and international reputation.

The editors would like to acknowledge and offer grateful thanks

for the input of all previous editions’ contributors, without whom

this new edition would not have been possible. In particular, we

are indebted to those former authors who step down with the

arrival of this new edition. They include: Elaine Anderson, John

Bevan, Andrew Bradbury, Nicki Colledge, Allan Cumming, Graham

Devereux, Jamie Douglas, Rebecca Ford, David Gawkrodger,

Neil Grubb, James Huntley, John Iredale, Robert Laing, Andrew

Longmate, Alastair MacGilchrist, Dilip Nathwani, Jane Norman,

John Olson, Paul O’Neill, Stephen Payne, Laura Robertson,

David Snadden, James C Spratt, Kum-Ying Tham, Steve Turner

and Janet Wilson.

We are particularly grateful to the following medical students,

who undertook detailed reviews of the book and gave us a wealth

of ideas to implement in this latest edition. We trust we have listed

all those who contributed, and apologise if any names have been

accidentally omitted: Layla Raad Abd Al-Majeed, Ali Adel Ne’ma

Abdullah, Aanchal Agarwal, Hend Almazroa, Alhan Alqinai, Amjed

Alyasseen, Chidatma Arampady, Christian Børde Arkteg, Maha

Arnaout, Rashmi Arora, Daniel Ashrafi, Herry Asnawi, Hemant Atri,

Ahmed Ayyad, Kainath N Azad, Sadaf Azam, Arghya Bandhu,

Jamie Barclay, Prithiv Siddarth Saravana Bavan, Rajarshi Bera,

Craig Betton, Apoorva Bhagat, Prachi Bhageria, Geethanjali

Bhas, Navin Bhatt, Shahzadi Nisar Bhutto, Abhishek Ghosh

Biswas, Tamoghna Biswas, Debbie Bolton, Claude Borg, Daniel

Buxton, Anup Chalise, Amitesh Kumar Chatterjee, Subhankar

Chatterjee, Farhan Ashraf Chaudhary, Aalia Chaudhry, Jessalynn

Chia, Bhaswati Chowdhury, Robin Chowdhury, Marshall Colin,

Michael Collins, Margaret Cooper, Barbara Corke, Andrea Culmer,

Gowtham Varma Dantuluri, Abhishek Das, Sonali Das, Aziz Dauti,

Mark Davies, Adam Denton, Muinul Islam Dewan, Greg Dickman,

Hengameh Ahmad Dokhtjavaherian, Amy Edwards, Muhammad

Eimaduddin, Laith Al Ejeilat, Divya G Eluru, Emmanuel Ernest, El

Bushra El Fadil, Fathima Ashfa Mohamed Faleel, Malcolm Falzon,

Emma Farrington, Noor Fazal, Sultana Ferdous, Matthew Formosa,

Brian Forsyth, David Fotheringham, Bhargav Gajula, Dariimaa

Ganbat, Lauren Gault, Michaela Goodson, Mounika Gopalam,

Ciaran Grafton-Clarke, Anthony Gunawan, Aditya Gupta, Digvijay

Gupta, Kshitij Gupta, Sonakshi Gupta, Md. Habibullah, Kareem

Haloub, Akar Jamal Hamasalih, James Harper, Bruce HarperMcDonald, Jon Harvey, Alexandra Hawker, Raja K Haynes, Emma

Hendry, Malik Hina, Bianca Honnekeri, Justina Igwe, Chisom

Ikeji, Sushrut Ingawale, Mohammad Yousuf ul Islam, Sneha Jain,

Maria Javed, Ravin Jegathnathan, Helge Leander B Jensen,

Li Jie, Ali Al Joboory, Asia Joseph, Christopher Teow Kang

Jun, Janpreet Kainth, Ayush Karmacharya, JS Karthik, Aneesh

Karwande, Adhishesh Kaul, Alper Kaymak, Ali Kenawi, Abdullah

Al Arefin Khadem, Haania Khan, Muhammad Hassan Khan,

Sehrish Khan, Shrayash Khare, Laith Khweir, Ankit Kumar, Vinay

Kumar, Ibrahim Lafi, Armeen Lakhani, Christopher Lee, David Lee,

Benjamin Leeves, Soo Ting Joyce Lim, Chun Hin Lo, Lai Hing Loi,

Chathura Mihiran Maddumabandara, Joana Sousa Magalhães,

Aditya Mahajan, Mahabubul Islam Majumder, Aaditya Mallik,

Mithilesh Chandra Malviya, Santosh Banadahally Manjegowda,

Jill Marshall, Balanuj Mazumdar, Alan David McCrorie, Paras

Mehmood, Kartik Mittal, Mahmood Kazi Mohammed, Amber

Moorcroft, Jayne Murphy, Sana Mustafa, Arvi Nahar, Akshay

Prakash Narad, Shehzina Nawal, Namia Nazir, Viswanathan

Neelakantan, Albero Nieto, Angelina Choong Kin Ning, Faizul

Nordin, Mairead O’Donoghue, Joey O’Halloran, Amit Kumar Ojha,

Ifeolu James Oyedele, Anik Pal, Vidit Panchal, Asha Pandu, Bishal

Panthi, Jacob Parker, Ujjawal Paudel, Tanmoy Kumar Paul, Kate

Perry, Daniel Pisaru, David Potter, Dipesh Poudel, Arijalu Syaram

Putra, Janine Qasim, Muhammad Qaunayn Qays, Mohammad

Qudah, Jacqueline Quinn, Varun MS Venkat Raghavan, Md.

Rahmatullah, Ankit Raj, Jerin Joseph Raju, Prasanna A Ramana,

Ashwini Dhanraj Rangari, Anurag Ramesh Rathi, Anam Raza,

Rakesh Reddy, Sudip Regmi, Amgad Riad, Patel Riya, Emily

Robins, Grace Robinson, Muhammad’Azam Paku Rozi, Cosmin

Rusneac, Ahmed Sabra, Anupama Sahu, Mohammad Saleh,

Manjiri Saoji, Saumyadip Sarkar, Rakesh Kumar Shah, Basil Al

Shammaa, Sazzad Sharhiar, Anmol Sharma, Homdutt Sharma,

Shivani Sharma, Shobhit Sharma, Johannes Iikuyu Shilongo,

Dhan Bahadur Shrestha, Pratima Shrestha, Anurag Singh,

Kareshma Kaur Ranjit Singh, Nishansh Singh, Aparna Sinha,

Liam Skoda, Ethan-Dean Smith, Prithviraj Solanki, Meenakshi

Sonnilal, Soundarya Soundararajan, Morshedul Islam Sowrav,

Kayleigh Spellar, Siddharth Srinivasan, Pradeep Srivastava,

Anthony Starr, Michael Suryadisastra, Louisa Sutton, Komal

Ashok Tapadiya, Areeba Tariq, Imran Tariq, Jia Chyi Tay, Javaria

Tehzeeb, Daniel Theron, Michele Tosi, Pagavathbharathi Sri Balaji

Vidyapeeth, Amarjit Singh Vij, Cathrine Vincent, Ghassan Wadi,

Amirah Abdul Wahab, James Warrington, Luke Watson, Federico

Ivan Weckesser, Ben Williamson, Kevin Winston, Kyi Phyu Wint,

Harsh Yadav, Saroj Kumar Yadav, Amelia Yong, Awais Zaka

and Nuzhat Zehra.

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How to make

the most of this book

The purpose of this book is to document and explain how to:

• interact with a patient as their doctor

• take a history from a patient

• examine a patient

• formulate your findings into differential diagnoses

• rank these in order of probability

• use investigations to support or refute your differential

diagnosis.

Initially, when you approach a section, we suggest that you

glance through it quickly, looking at the headings and how it

is laid out. This will help you to see in your mind’s eye the

framework to use.

Learn to speed-read. It is invaluable in medicine and in life

generally. Most probably, the last lesson you had on reading

was at primary school. Most people can dramatically improve

their speed of reading and increase their comprehension by

using and practising simple techniques.

Try making mind maps of the details to help you recall and

retain the information as you progress through the chapter. Each

of the systems chapters is laid out in the same order:

• Introduction: anatomy and physiology.

• The history: common presenting symptoms, what

questions to ask and how to follow them up.

• The physical examination: what and how to examine.

• Investigations: how to select the most relevant and

informative initial tests, and how these clarify the diagnosis.

• Objective Structured Clinical Examination (OSCE)

examples: a couple of short clinical scenarios included to

illustrate the type of problems students may meet in an

OSCE assessment of this system.

• Integrated examination sequence: a structured list of steps

to be followed when examining the system, intended as a

prompt and revision aid.

Return to this book to refresh your technique if you have

been away from a particular field for some time. It is surprising

how quickly your technique deteriorates if you do not use it

regularly. Practise at every available opportunity so that you

become proficient at examination techniques and gain a full

understanding of the range of normality.

Ask a senior colleague to review your examination technique

regularly; there is no substitute for this and for regular practice.

Listen also to what patients say – not only about themselves

but also about other health professionals – and learn from these

comments. You will pick up good and bad points that you will

want to emulate or avoid.

Finally, enjoy your skills. After all, you are learning to be able

to understand, diagnose and help people. For most of us, this

is the reason we became doctors.

Examination sequences

Throughout the book there are outlines of techniques that you

should follow when examining a patient. These are identified

with a red ‘Examination sequence’ heading. The bullet-point list

provides the exact order in which to undertake the examination.

To help your understanding of how to perform these