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

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,