Book Review

Clinical Examination

N Engl J Med 1993; 328:293-294January 28, 1993

Article

Clinical Examination
By Owen Epstein, G. David Perkin, David P. de Bono, and John Cookson, with a contribution by Neil Solomons. Approximately 500 pp., illustrated. New York, Gower Medical, 1992. $49.95. (Distributed in the U.S. by Raven Press, New York.) ISBN: 0-397-44723-X

Despite the increasing reliance of clinical medicine on technology, the clinical examination remains the cornerstone of diagnosis and therapy, and the physician-patient encounter remains pivotal in the patient's satisfaction with health care. Thus, textbooks that teach physical diagnosis will remain vitally important, not only to medical students but also to seasoned clinicians, who occasionally need to refresh their physical-diagnosis skills. However, textbooks on physical diagnosis often tend to be dry and bland. To their credit, Epstein et al. have created a book that is robust, interesting, and a visual delight. The book begins with chapters on the medical record, interviewing techniques and history taking, and the general examination. Subsequent chapters cover aspects of history taking and physical examination involving each of the various organ systems.

There are a number of excellent chapters, especially those on the cardiovascular and respiratory systems and the abdomen. The chapter on the nervous system also stands out, with its detailed coverage of neuroanatomy and examination of each cranial nerve and its approach to the examination of the unconscious patient. The book is easy to read, lucid, and concise. There are instances of redundancy, but these are generally of educational value. There are some printing errors, and chapter 3 cannot be found in the table of contents, but these problems are not unexpected in a first edition, I suspect.

One unique aspect of the book is its ambitious effort to teach not just physical findings in both normal and disease states, but also the pathophysiology underlying the diseases. Thus, substantial portions of many chapters are devoted to the structure and function of organ systems, normal and abnormal physiology, and even occasionally biochemistry and histology. This effort is supported by many lucid tables, diagrams, photographs, and radiographs.

The authors also cover clinical syndromes and differential diagnosis. For example, in the chapter on respiratory disease, the importance of obtaining a thorough occupational history is emphasized, and there is also a table listing various occupational diseases and the agents that cause them. Likewise, in the chapter on the cardiovascular system, the reader is taught how to examine the heart and, in addition, a number of pages are devoted to the signs, symptoms, differential diagnosis, and diagnostic evaluation of specific cardiovascular conditions, from myocardial infarction or deep-vein thrombosis to endocarditis. Here, too, numerous colorful photographs and tables supplement the text.

The authors have successfully placed the teaching of physical-diagnosis skills in the best possible context for these skills to be learned with interest and retained. The reader is brought along logically from descriptions of normal and then disordered structure and function, to explanations of the symptoms and signs of that disordered structure and function, and finally to vignettes of disease states with those symptoms and signs. This feature and the outstanding graphics make the reading enjoyable indeed.

The book is not without some weaknesses. It deals only with the examination of adults, so students interested in neonatal and pediatric examination will have to look elsewhere. The physical-diagnosis thread of the book occasionally gets lost in pathophysiology and too many tables and figures. This is particularly a problem in chapter 3, in which the authors attempt to cover too many disparate topics.

Another shortcoming is the superficial treatment of many aspects of history taking. The crucial history of the presenting illness is dealt with painfully briefly. Several key aspects of history taking are hardly covered at all, such as when to use open-ended and closed-ended questioning techniques and how to obtain an accurate, thorough, and chronologic narrative thread. The medical history, medication history, social history, use of tobacco and alcohol, and sexual history are all treated too briefly to be of much help in building major skills in these areas.

Finally, the authors seem to have shied away from many of the psychosocial aspects of the doctor-patient encounter, including the physician's and patient's goals for the interview and the emotional and behavior-management aspects of the history taking and examination. More attention could also have been given to ways of dealing with patients' fears and other emotions, and a section on the approach to hostile, anxious, or otherwise difficult patients would have been welcomed.

Because of its shortcomings, teachers of physical diagnosis will no doubt need to supplement Clinical Examination with other textbooks that deal in greater depth with general history taking and doctor-patient interaction skills. However, the book is reasonably priced, and its treatment of physical diagnosis according to organ systems is excellent. Overall, it is an ambitious and colorful addition to the field, and students of physical diagnosis will find it very enjoyable.

Ronald C. Silvestri, M.D.
New England Deaconess Hospital, Boston, MA 02215