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2015v1.0

Macleod’s

Clinical Examination

Content Strategist: Laurence Hunter

Content Development Specialist: Helen Leng

Project Manager: Anne Collett

Designer: Miles Hitchen

Illustration Manager: Karen Giacomucci

John Macleod (1915–2006)

John Macleod was appointed consultant physician at the Western General Hospital,

Edinburgh, in 1950. He had major interests in rheumatology and medical education.

Medical students who attended his clinical teaching sessions remember him as

an inspirational teacher with the ability to present complex problems with great

clarity. He was invariably courteous to his patients and students alike. He had an

uncanny knack of involving all students equally in clinical discussions and used

praise rather than criticism. He paid great attention to the value of history taking

and, from this, expected students to identify what particular aspects of the physical

examination should help to narrow the diagnostic options.

His consultant colleagues at the Western welcomed the opportunity of contributing

when he suggested writing a textbook on clinical examination. The book was first

published in 1964 and John Macleod edited seven editions. With characteristic

modesty he was very embarrassed when the eighth edition was renamed Macleod’s

Clinical Examination. This, however, was a small way of recognising his enormous

contribution to medical education.

He possessed the essential quality of a successful editor – the skill of changing

disparate contributions from individual contributors into a uniform style and format

without causing offence; everybody accepted his authority. He avoided being

dogmatic or condescending. He was generous in teaching others his editorial

skills and these attributes were recognised when he was invited to edit Davidson’s

Principles and Practice of Medicine.

Macleod’s Examination Clinical

Edited by

J Alastair Innes

BSc PhD FRCP(Ed)

Consultant Physician, Respiratory Unit, Western General

Hospital, Edinburgh; Honorary Reader in Respiratory Medicine,

University of Edinburgh, UK

Anna R Dover

PhD FRCP(Ed)

Consultant in Diabetes, Endocrinology and General Medicine,

Edinburgh Centre for Endocrinology and Diabetes, Royal

Infirmary of Edinburgh; Honorary Clinical Senior Lecturer,

University of Edinburgh, UK

Karen Fairhurst

PhD FRCGP

General Practitioner, Mackenzie Medical Centre, Edinburgh;

Clinical Senior Lecturer, Centre for Population Health Sciences,

University of Edinburgh, UK

Illustrations by Robert Britton and Ethan Danielson

14th Edition

Edinburgh London New York Oxford Philadelphia St Louis Sydney 2018

© 2018 Elsevier Ltd. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,

including photocopying, recording, or any information storage and retrieval system, without permission in writing from

the publisher. Details on how to seek permission, further information about the publisher’s permissions policies and

our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency,

can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the publisher (other than

as may be noted herein).

The

publisher’s

policy is to use

paper manufactured

from sustainable forests

First edition 1964

Second edition 1967

Third edition 1973

Fourth edition 1976

Fifth edition 1979

Sixth edition 1983

Seventh edition 1986

Eighth edition 1990

Ninth edition 1995

Tenth edition 2000

Eleventh edition 2005

Twelfth edition 2009

Thirteenth edition 2013

Fourteenth edition 2018

ISBN 978-0-7020-6993-2

International ISBN 978-0-7020-6992-5

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any

information, methods, compounds or experiments described herein. Because of rapid advances in the medical

sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent

of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to

persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any

methods, products, instructions, or ideas contained in the material herein.

Printed in Europe

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contents

Preface vii

Acknowledgements ix

How to make the most of this book xi

Clinical skills videos xiii

Contributors xv

SECTION 1 PRINCIPLES OF CLINICAL HISTORY AND EXAMINATION 1

1 Managing clinical encounters with patients 3

Karen Fairhurst, Anna R Dover, J Alastair Innes

2 General aspects of history taking 9

J Alastair Innes, Karen Fairhurst, Anna R Dover

3 General aspects of examination 19

Anna R Dover, J Alastair Innes, Karen Fairhurst

SECTION 2 SYSTEM-BASED EXAMINATION 37

4 The cardiovascular system 39

Nicholas L Mills, Alan G Japp, Jennifer Robson

5 The respiratory system 75

J Alastair Innes, James Tiernan

6 The gastrointestinal system 93

John Plevris, Rowan Parks

7 The nervous system 119

Richard Davenport, Hadi Manji

8 The visual system 151

Shyamanga Borooah, Naing Latt Tint

9 The ear, nose and throat 171

Iain Hathorn

10 The endocrine system 193

Anna R Dover, Nicola Zammitt

11 The reproductive system 211

Oliver Young, Colin Duncan, Kirsty Dundas, Alexander Laird

vi • Contents

12 The renal system 237

Neeraj Dhaun, David Kluth

13 The musculoskeletal system 251

Jane Gibson, Ivan Brenkel

14 The skin, hair and nails 283

Michael J Tidman

SECTION 3 APPLYING HISTORY AND EXAMINATION SKILLS IN SPECIFIC SITUATIONS 295

15 Babies and children 297

Ben Stenson, Steve Cunningham

16 The patient with mental disorder 319

Stephen Potts

17 The frail elderly patient 329

Andrew Elder, Elizabeth MacDonald

18 The deteriorating patient 339

Ross Paterson, Anna R Dover

19 The dying patient 347

Anthony Bateman, Kirsty Boyd

SECTION 4 PUTTING HISTORY AND EXAMINATION SKILLS TO USE 353

20 Preparing for assessment 355

Anna R Dover, Janet Skinner

21 Preparing for practice 361

Karen Fairhurst, Gareth Clegg

Index 375

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