Book Review

Difficult Diagnosis 2

N Engl J Med 1993; 328:68-69January 7, 1993

Article

Difficult Diagnosis 2
Edited by Robert B. Taylor. 548 pp., illustrated. Philadelphia, W.B. Saunders, 1992. $60. ISBN: 0-7216-3481-8

This multiauthored work describes an approach to the differential diagnosis of 71 clinical problems or symptoms encountered in a primary care practice. An earlier volume, Difficult Diagnosis (Philadelphia: W.B. Saunders, 1985), presented an entirely different set of clinical problems. Some of the problems covered in Difficult Diagnosis 2 are extremely common (chronic abdominal pain, dysuria, fatigue, and insomnia), whereas others are uncommon (amnesia and interstitial pulmonary disease). For each clinical problem the authors seek to provide a comprehensive review of the most likely causes as well as the “zebras.” The history, physical examination, and laboratory tests pertinent to each problem are described. Relatively little attention is paid to therapy.

In a world of information overload, any new book should provide information that is either new or better than that in existing books. We asked ourselves whether this book meets that test, in comparison with general textbooks of internal medicine, pediatrics, and family medicine, or with a number of other books dedicated to differential diagnosis. We concluded that some chapters succeed in this regard, whereas most do not. The writing is quite uneven. While some chapters are clearly written, comprehensive, and timely (the discussions of thyroid enlargement, transient ischemic attacks, and chronic cough are examples), others are disorganized, imprecise, and dated. Some information is unnecessary or inaccurate: “Jaundice reflects hepatic excretory dysfunction of a hepatocellular or obstructive nature”; “Hyperthyroidism is an anxiety-related endocrine condition characterized by an excess of thyroid hormone”; “Hypoxia of any cardiopulmonary etiology induces nervousness.” Some chapters use jargon or arcane terms that will be unfamiliar or unclear to many physicians. In general, better use could have been made in many chapters of tables, figures, and algorithms to sharpen the presentation; instead, the reader often needs to wade through discursive prose. In some cases, an excessive amount of laboratory evaluation is recommended (an example is the diagnostic approach to Raynaud's phenomenon).

Despite its drawbacks, Difficult Diagnosis 2 has some strengths. Specific, clearly described, and well-defended clinical strategies are presented in some chapters (examples cover the diagnostic assessment of breast masses and of thyroid enlargement). Some topics are covered more extensively than in most general textbooks (for example, the evaluation of oral ulcers and of insomnia). There is admirable attention to the somatic manifestations of primary psychiatric disease.

On balance, some primary care physicians may find this a useful book to have on the shelf, especially as a quick reference for review of the fundamentals of frequently encountered clinical problems. Unfortunately, the chapters are not of uniformly high quality.

Anthony L. Komaroff, M.D.
Thomas F. Lansdale, III, M.D.
Brigham and Women's Hospital, Boston, MA 02115