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MD Consult: Books: Goldman: Cecil Medicine: APPROACH TO THE PATIENT

Goldman: Cecil Medicine, 23rd ed.

Copyright © 2007 Saunders, An Imprint of Elsevier

APPROACH TO THE PATIENT

Patients commonly have complaints (symptoms). These symptoms may or may not be accompanied by abnormalities on examination (signs) or on laboratory testing. Conversely, asymptomatic patients may have signs or laboratory abnormalities, and laboratory abnormalities can occur in the absence of symptoms or signs.

Symptoms and signs commonly define syndromes, which may be the common final pathway of a wide range of pathophysiologic alterations. The fundamental basis of internal medicine is that diagnosis should elucidate the pathophysiologic explanation for symptoms and signs so that therapy may improve the underlying abnormality, not just attempt to suppress the abnormal symptoms or signs.

When patients seek care from physicians, they may have manifestations or exacerbations of known conditions, or they may have symptoms and signs that suggest malfunction of a particular organ system. Sometimes the pattern of symptoms and signs is highly suggestive or even pathognomonic for a particular disease process. In these situations, in which the physician is focusing on a particular disease, the Cecil Textbook of Medicine provides scholarly, yet practical approaches to the epidemiology, pathobiology, clinical manifestations, diagnosis, treatment, prevention, and prognosis of entities such as acute myocardial infarction ( Chapter 72 ), chronic obstructive lung disease ( Chapter 88 ), obstructive uropathy ( Chapter 124 ), inflammatory bowel disease ( Chapter 144 ), gallstones ( Chapter 159 ), rheumatoid arthritis ( Chapter 285 ), hypothyroidism ( Chapter 244 ), tuberculosis ( Chapter 345 ), and virtually any known medical condition in adults.

Many patients, however, have undiagnosed symptoms, signs, or laboratory abnormalities that cannot be immediately ascribed to a particular disease or cause. Whether the initial manifestation is chest pain ( Chapter 48 ), diarrhea ( Chapter 143 ), neck or back pain ( Chapter 423 ), or a variety of more than 100 common symptoms, signs, or laboratory abnormalities, the Cecil Textbook of Medicine provides tables, figures, and entire chapters to guide the approach to diagnosis and therapy ( Table 1-1 ). By virtue of this dual approach to known disease as well as to undiagnosed abnormalities, this textbook, similar to the modern practice of medicine, applies directly to patients regardless of their mode of manifestation or degree of previous evaluation.


TABLE 1-1   — 
GUIDE TO THE APPROACH TO COMMON SYMPTOMS, SIGNS, AND LABORATORY ABNORMALITIES

    Chapter Specific Tables or Figures
SYMPTOMS
CONSTITUTIONAL
Fever 302 Tables 302-1 to 302-8
Fatigue 293 Table 293-3
Poor appetite 134 Table 134-1
Weight loss 134 , 233 , 238 Figure 134-3 ; Table 134-4
Obesity 233 Figure 233-2
Snoring, sleep disturbances 101 , 429 Table 429-3
HEAD, EYES, EARS, NOSE, THROAT
Headache 421 Table 421-1
Visual loss, transient 449 Tables 449-2 , 450-1
Ear pain 452 Table 452-1
Hearing loss 454 Figure 454-1
Ringing in ears (tinnitus) 454 Figure 454-2
Vertigo 454 Figure 454-3
Nasal congestion 452 Figure 452-1
Rhinitis or sneezing 272 Figure 272-2
Loss of smell or taste 453 Table 453-1
Dry mouth 451 Table 451-7
Sore throat 455 Figure 455-2 ; Table 455-1
Hoarseness 455  
CARDIOPULMONARY
Chest pain 48 Table 48-2
Bronchitis 96  
Shortness of breath 48 , 83 Figures 48-1 , 83-1
Palpitations 48 , 61 Figure 61-1 ; Tables 48-3 , 61-1
Dizziness 48 , 61 , 427 Figure 61-1 ; Table 427-1
Syncope 61 , 427 Figures 61-1 , 427-1 ; Tables 61-1 , 427-1 , 427-2
Cardiac arrest 62 Figures 62-2 , 62-3
Cough 83 Figure 83-1 ; Tables 83-1 , 83-2
Hemoptysis 83 Tables 83-5 , 83-6
GASTROINTESTINAL
Nausea and vomiting 134 Table 134-3
Dysphagia, odynophagia 134 , 140 Table 134-1
Hematemesis 137 , 157 Figure 137-3 ; Table 137-1
Heartburn/dyspepsia 139 , 140 Figures 139-2 , 140-3
Abdominal pain:
  Acute 134 , 145 Figure 134-1 ; Table 134-2
  Chronic 134 , 139 Figure 134-2 ; Table 134-2
Diarrhea 139 , 143 Figures 139-1 , 143-2 , 143-3 , 143-8 to 143-10
Melena 137 Figure 137-4 ; Table 137-4
Constipation 138 , 139 Figures 138-4 , 139-1 ; Table 138-2
Fecal incontinence 148 Figure 148-4
Anal pain 148 Table 148-2
GENITOURINARY
Dysuria 306 , 307  
Frequency 130 , 306  
Incontinence 24 Figure 24-1 ; Table 24-3
Urinary obstruction 124 Tables 124-1 to 124-3
Renal colic 127 Figure 127-3
Vaginal discharge 307  
Menstrual irregularities 256 Figure 256-9 ; Tables 256-3 to 256-5
Female infertility 256 Table 256-6
Hot flushes 262 Table 262-1
Erectile dysfunction 253  
Male infertility 253 Figures 253-11 , 253-12
MUSCULOSKELETAL
Neck or back pain 423 Figure 423-3 ; Tables 423-1 to 423-4
Painful joints 277 Table 277-2
EXTREMITIES
Swollen feet, ankles, or legs
  bilateral 48 Figure 48-8
  unilateral 81 Figure 81-2 ; Table 81-2
Claudication 79 Figure 79-2
NEUROLOGIC
Weakness 418 , 446 , 447 , 448 Tables 418-1 , 446-2
Sensory loss 418 , 446 Tables 446-1 , 446-4 to 446-7
Memory loss 425 Figures 425-1 , 425-2 ; Tables 425-1 to 425-6
Abnormal gait 418 Table 418-2
Seizures 426 Tables 426-1 to 426-4
INTEGUMENTARY
Abnormal bleeding 178 Table 178-1
Rash 462 Figure 462-1 ; Tables 462-1 to 462-4
Hives 273 , 466 Figure 273-2 ; Tables 273-1 , 466-1
Abnormal pigmentation 467 Table 467-2
Hirsutism and alopecia 261 , 467 Tables 261-1 , 467-5
SIGNS
VITAL SIGNS
Fever 302 , 303 Tables 302-1 to 302-8
Hypothermia 7 , 110 Table 110-4
Tachycardia/bradycardia 7 , 52 , 61 , 65 Figures 61-2 , 61-3
Hypertension 66 Table 66-4
Hypotension/shock 7 , 107 Figure 107-1
Altered respiration 7 , 86 , 105 Tables 86-1 , 105-2
HEAD, EYES, EARS, NOSE, THROAT
Red eye 449 Table 449-4
Dilated pupil 450 Figure 450-4
Nystagmus 450 Table 450-5
Papilledema 450 Table 450-2
Strabismus 450 Figure 450-6
Jaundice 150 Figure 150-3 ; Tables 150-1 to 150-3
Otitis 452 Figure 452-1
Sinusitis 272 , 452 Figure 452-1
Oral ulcer 451 Tables 451-1 , 451-3 , 451-4
Salivary gland enlargement 451 Table 451-6
NECK
Neck mass 200 Figure 200-3
Lymphadenopathy 174 Tables 174-1 , 174-2 , 174-5
Thyroid nodule 244 Figure 244-4
Thyromegaly/goiter 244 Figures 244-1 , 244-3
BREAST
Breast mass 208  
LUNGS
Wheezes 83 Table 83-3
CARDIAC
Heart murmur or extra sounds 48 Figure 48-4 ; Tables 48-6 , 48-7
Jugular venous distention 48 Table 48-5
Carotid pulse abnormalities 48 Figure 48-5
ABDOMEN
Hepatomegaly 149 Figure 149-4
Splenomegaly 174 Tables 174-6 , 174-8
Acute abdomen 145 Tables 145-1 to 145-3
Abdominal swelling/ascites 146 , 157 Table 157-3
Rectal bleeding/positive stool 137 , 203 Figures 137-4 , 137-5 ; Table 137-5
Hemorrhoids 148 Table 148-1
GENITOURINARY
Scrotal mass 210 Figure 210-1
Vaginal discharge 307  
Genital ulcers or warts 307  
MUSCULOSKELETAL/EXTREMITIES
Arthritis 277  
Edema 48 Figure 48-8
Cyanosis 48  
Clubbing 48  
NEUROLOGIC
Delirium 26 Figure 26-1 ; Tables 26-1 , 26-2
Psychiatric disturbances 420 Tables 420-1 , 420-3 to 420-5 , 420-7 to 420-9
Coma 428 Table 428-1
Stroke 431 Figure 431-4
Movement disorders 434 Tables 434-1 to 434-7
Neuropathy 446 Figure 446-1
SKIN AND NAILS
Suspicious mole 214 Table 214-1
Nail diseases 467 Table 467-4
COMMON LABORATORY ABNORMALITIES
HEMATOLOGY/URINALYSIS
Anemia 162 Figure 162-2 ; Tables 162-4 to 162-6
Polycythemia 172 Figure 172-3 ; Table 172-2
Leukocytosis 173 Figure 173-7 ; Table 173-4
Lymphocytosis 173 Table 173-7
Monocytosis 173 Table 173-6
Eosinophilia 176 Figure 176-2 ; Table 176-1
Neutropenia 173 Figures 173-2 , 173-5 ; Table 173-1
With fever 303 Figures 303-1 , 303-2
Thrombocytosis 177 Figure 177-1 ; Table 177-2
Thrombocytopenia 179 Table 179-1
Prolonged PT or PTT 178 Figures 178-3 , 178-4
Urinalysis 115 Table 115-1
CHEMISTRIES
Abnormal liver enzymes 150 Figures 150-3 to 150-5
Elevated BUN/creatinine    
Acute 121 Figure 121-1 ; Tables 121-1 to 121-5
Chronic 131 Table 131-1
Hyperglycemia 247 , 248 Table 248-2
Hypoglycemia 249 Table 249-1
Electrolyte abnormalities 117 , 118 Tables 117-3 , 117-4 , 117-6 , 118-2 , 118-3
Acid–base disturbances 119 Tables 119-1 to 119-5
Hypercalcemia 266 Table 266-1
Hypocalcemia 266 Table 266-4
Hypo- and hyperphosphatemia 120 Tables 120-2 , 120-3
Elevated Pco2 86 Figure 86-3
CHEST RADIOGRAPH/ECG
Solitary pulmonary nodule 201 Figure 201-5
Pleural effusion 100 Table 100-5
Suspected lung cancer 201 Figure 201-4
ECG abnormalities 52 Tables 52-2 to 52-5

BUN = blood urea nitrogen; ECG = electrocardiogram; PT = prothrombin time; PTT = partial thromboplastin time.

The patient-physician interaction proceeds through many phases of clinical reasoning and decision making. The interaction begins with an elucidation of complaints or concerns, followed by inquiries or evaluations to address these concerns in increasingly precise ways. The process commonly requires a careful history or physical examination, ordering of diagnostic tests, integration of clinical findings with test results, understanding of the risks and benefits of the possible courses of action, and careful consultation with the patient and family to develop future plans. Physicians can increasingly call on a growing literature of evidence-based medicine to guide the process so that benefit is maximized while respecting individual variations in different patients. Throughout the Cecil Textbook of Medicine, the best current evidence is highlighted with specific grade A references that can be accessed directly in the electronic version.

The increasing availability of evidence from randomized trials to guide the approach to diagnosis and therapy should not be equated with “cookbook” medicine. Evidence and the guidelines that are derived from it emphasize proven approaches for patients with specific characteristics. Substantial clinical judgment is required to determine whether the evidence and guidelines apply to individual patients and to recognize the occasional exceptions. Even more judgment is required in the many situations in which evidence is absent or inconclusive. Evidence must also be tempered by patients’ preferences, although it is a physician’s responsibility to emphasize evidence when presenting alternative options to the patient. The adherence of a patient to a specific regimen is likely to be enhanced if the patient also understands the rationale and evidence behind the recommended option.

To care for a patient as an individual, the physician must understand the patient as a person. This fundamental precept of doctoring includes an understanding of the patient’s social situation, family issues, financial concerns, and preferences for different types of care and outcomes, ranging from maximum prolongation of life to the relief of pain and suffering ( Chapters 2 and 3 ). If the physician does not appreciate and address these issues, the science of medicine cannot be applied appropriately, and even the most knowledgeable physician will fail to achieve the desired outcomes.

Even as physicians become increasingly aware of new discoveries, patients can obtain their own information from a variety of sources, some of which are of questionable reliability. The increasing use of alternative and complementary therapies ( Chapter 36 ) is an example of patients’ frequent dissatisfaction with prescribed medical therapy. Physicians should keep an open mind regarding unproven options but must advise their patients carefully if such options may carry any degree of potential risk, including the risk that they may be relied on to substitute for proven approaches. It is crucial for the physician to have an open dialogue with the patient and family regarding the full range of options that either may consider.

The physician does not exist in a vacuum, but rather as part of a complicated and extensive system of medical care and public health. In premodern times and even today in some developing countries, basic hygiene, clean water, and adequate nutrition have been the most important ways to promote health and reduce disease. In developed countries, adoption of healthy lifestyles, including better diet ( Chapter 232 ) and appropriate exercise ( Chapter 14 ), is the cornerstone to reducing the epidemics of obesity ( Chapter 239 ), coronary disease ( Chapter 69 ), and diabetes ( Chapter 248 ). Public health interventions to provide immunizations ( Chapter 16 ) and reduce injuries ( Chapter 15 ) and the use of tobacco ( Chapter 30 ), illicit drugs ( Chapter 32 ), and excess alcohol ( Chapter 31 ) can collectively produce more health benefits than nearly any other imaginable health intervention.

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