DeGowin diagnostic examination

DeGowin’s
DIAGNOSTIC
EXAMINATION


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DeGowin’s
DIAGNOSTIC
EXAMINATION
Ninth Edition

Richard F. LeBlond, MD, MACP
Professor of Internal Medicine (Clinical)
The University of Iowa College of Medicine
Iowa City, Iowa

Richard L. DeGowin, MD, FACP
Professor Emeritus of Internal Medicine
The University of Iowa College of Medicine
Iowa City, Iowa

Donald D. Brown, MD, FACP
Professor of Internal Medicine
The University of Iowa College of Medicine
Iowa City, Iowa

Illustrated by
Elmer DeGowin, MD,
Jim Abel,
and Shawn Roach

New York Chicago San Francisco
Lisbon London Madrid Mexico City Milan
New Delhi San Juan Seoul Singapore Sydney Toronto


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publisher.
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To our patients,
who allow us to practice our art,
encourage us with their confidence,
and humble us with their courage.
— Richard F. LeBlond


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It is not easy to give exact and complete details of an operation in writing; but the
reader should form an outline of it from the description.
— Hippocrates
“On Joints”

[Studies] perfect Nature, and are perfected by Experience: For Natural Abilities,
are like Natural Plants, that need proyning by study: And Studies themselves, due
give forth Directions too much at Large, except they be bounded in by experience.
Crafty Men Contemne Studies; Simple Men Admire them; And Wise Men Use
them; For they teach not their owne Use; But that is a Wisdome without them,

and above them, won by Observation. Reade not to Contradict, and Confute; Nor
to Beleeve and Take for granted; Nor to Finde Talke and Disourse; But to weigh
and Consider.
— Francis Bacon
“Of Studies”

It is only by persistent intelligent study of disease upon a methodical plan of examination that a man gradually learns to correlate his daily lessons with the facts
of his previous experience and that of his fellows, and so acquires clinical wisdom.
— Sir William Osler
Sources for Quotations:
Brecht quotation from: Bertolt Brecht. Poems 1913–1956. London, Methuen London Ltd., 1979.
Eliot quotation from: T.S. Eliot. The Complete Poems and Plays, 1909–1950. New York, Harcourt,
Brace & World, Inc., 1971.
Frazer quotation from: Sir James George Frazer. The Golden Bough, A Study in Magic and Religion,
abridged edition. New York, MacMillan Publishing Company, 1922.
Hippocrates quotation from: Jacques Jouanna (M.B. DeBevoise translator). Hippocrates. Baltimore, The Johns Hopkins University Press, 1999.
Osler quotation from: Sir William Osler. Aequanimitas, with other Addresses to Medical Students,
Nurses and Practictioners of Medicine. Philadelphia, P. Blakistons Son and Co., 1928.
Roethke quotations from: Theodore Roethke. On Poetry and Craft. Port Townsend, Washington
Copper Canyon Press, 2001.


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CONTENTS
xxi
xxv
xxvii

Preface
Common Abreviations
Introduction and User’s Guide

PART I
THE DIAGNOSTIC FRAMEWORK
1. Diagnosis

2

1. Why is Diagnosis Important?
2. Diseases and Syndromes: Communication and Entry to
the Medical Literature
A. The Diagnostic Examination
1. Stories: Listen, Examine, Interpret, Explain
2. Finding Clues to the Diagnosis
3. Select Hypotheses: Generate a Differential
Diagnosis
4. Cognitive Tests of the Diagnostic Hypotheses
5. Selection of Diagnostic Tests
6. Rare Diseases
7. Certainty and Diagnosis
8. Prognostic Uncertainty
9. Deferred Diagnoses
10. A Summary of the Diagnostic Process
11. Caveat
12. An Example of the Diagnostic Process
B. Other Examinations
1. The Autopsy
2. Other Varieties of Medical Examinations

2. History Taking and the Medical Record
A. Outline of the Medical Record
B. Procedure for Taking a History
1. Definition of the Medical History

ix

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2. Scope of the History
3. Methods in History Taking
4. Conducting the Interview
C. Completion of the Medical Record
1. Identification
2. The Informant
3. Chief Complaints (CC)
4. History of Present Illness (HPI)
5. Past Medical and Surgical History
6. Family History (FH)
7. Social History (SH)
8. Review of Systems (ROS)
9. Medications
10. Allergies and Medication Intolerances
11. Preventive Care Services
12. Advance Directives
13. Physical Examination (PE)
14. Laboratory
15. Assessment
16. The Plan
D. The Oral Presentation
E. Other Clinical Notes
1. Inpatient Progress Notes

2. Off-Service Note
3. Discharge Summary
4. Clinic Notes
F. The Patient’s Medical Record
1. Purposes
2. Physician’s Signature
3. Custody of the Record
G. Electronic Medical Records

3. The Screening Physical Examination
A. Methods for Physical Examination
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
B. Procedure for the Screening Physical Examination
1. Preparing for the Screening Examination
2. Performance of the Screening Examination

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Contents

xi

PART II
THE DIAGNOSTIC EXAMINATION
The Diagnostic Examination: Chapters 4 to 16

4. Vital Signs, Anthropometric Data, and Pain
A. Vital Signs
1. Body Temperature
2. The Pulse: Rate, Volume, and Rhythm
3. Respirations: Respiratory Rate and Pattern
4. Blood Pressure and Pulse Pressure
B. Anthropometric Data
1. Height
2. Weight
C. Pain
1. Diagnostic Attributes of Pain
2. Pain Syndromes

5. Non-Regional Systems and Diseases
A. Constitutional Symptoms
B. The Immune System
1. Two Common Syndromes
C. The Lymphatic System
1. Examination of the Lymph Nodes
2. Lymph Node Signs

3. Lymph Node Syndromes
D. The Hematopoietic System and Hemostasis
1. Red Blood Cell (Erythrocyte) Disorders
2. Neutrophil Disorders
3. Myeloproliferative Disorders and Acute Leukemia
4. Platelet Disorders
5. Coagulation Disorders
E. The Endocrine System
1. Diabetes and Hypoglycemia
2. Disorders of Thyroid Function
3. Disorders of Adrenal Function
4. Disorders of Parathyroid Function
5. Disorders of Pituitary Function

6. The Skin and Nails
A. Physiology of the Skin and Nails

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85

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xii

Contents

B. Functional Anatomy of the Skin and Nails
1. Epidermis
2. Dermis and Subcutaneous Tissue
3. The Fingernails
4. The Toenails
5. Skin Coloration
6. Hair
7. Sebaceous Glands
8. Eccrine (Sweat) Glands
9. Apocrine Glands
10. Nerves
11. Circulation of the Skin and Mucosa
12. Cutaneous Wound Healing and Repair
C. Examination of the Skin and Nails
D. Skin and Nail Symptoms
E. Skin and Nail Signs
1. Anatomic Distribution of Lesions
2. Pattern of Lesions
3. Morphology of Individual Lesions
4. Generalized Skin Signs
5. Changes in the Hair
6. Fingernail Signs
7. Arterial Circulation Signs
8. Purpura
9. Non-Purpuric Vascular Lesions
F. Common Skin and Nail Syndromes
1. Common Skin Disorders
2. Skin Infections and Infestations
3. Bullous Skin Diseases

4. Skin Manifestations of Systemic Diseases
5. Vascular Disorders
6. Skin Neoplasms

7. The Head and Neck
A. Major Systems of the Head and Neck
B. Functional Anatomy of the Head and Neck
1. The Scalp and Skull
2. The Face and Neck
3. The Ears
4. The Eyes
5. The Nose
6. The Mouth and Oral Cavity
7. The Larynx

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Contents

8. The Salivary Glands
9. The Thyroid Gland
C. Physical Examination of the Head and Neck
1. Examination of the Scalp, Face, and Skull
2. Examination of the Ears, Hearing, and Labyrinthine
Function
3. Examination of the Eyes, Visual Fields and
Visual Acuity
4. Examination of the Nose and Sinuses
5. Examination of the Lips, Mouth, Teeth, Tongue,
and Pharynx
6. Examination of the Larynx
7. Examination of the Salivary Glands
8. Examination of the Temporomandibular Joint
9. Examination of the Neck
10. Examination of the Lymph Nodes
11. Examination of the Vascular System
D. Head and Neck Symptoms
1. General Symptoms
2. Skull, Scalp, and Face Symptoms
3. Ear Symptoms
4. Eye Symptoms
5. Nose Symptoms
6. Lip, Mouth, Tongue, Teeth, and Pharynx
Symptoms
7. Larynx Symptoms
8. Salivary Gland Symptoms
9. Neck Symptoms

E. Head and Neck Signs
1. Scalp, Face, Skull, and Jaw Signs
2. Ear Signs
3. Eye Signs
4. Nose and Sinus Signs
5. Lip Mouth, Teeth, Tongue and Pharynx Signs
6. Larynx and Trachea Signs
7. Salivary Gland Signs
8. Neck Signs
9. Thyroid Signs
F. Head and Neck Syndromes
1. Scalp, Face, Skull, and Jaw Syndromes
2. Eye Syndromes
3. Ear Syndromes
4. Nose and Sinus Syndromes

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Contents

5. Oral Syndromes (Lips, Mouth, Tongue, Teeth, and
Pharynx)
6. Larynx Syndromes
7. Salivary Gland Syndromes
8. Thyroid Goiters and Nodules

8. The Chest: Chest Wall, Pulmonary, and Cardiovascular
Systems; The Breasts
SECTION 1
Chest Wall, Pulmonary, and Cardiovascular Systems
A. Major Systems and Physiology
1. The Thoracic Wall
2. The Lungs and Pleura
3. The Cardiovascular System
B. Superficial Thoracic Anatomy
1. The Chest Wall
2. The Lungs and Pleura
3. The Heart and Precordium
C. Physical Examination of the Chest and Major Vessels
1. Examination of the Rib Cage and Thoracic Musculature
2. Examination of the Lungs and Pleura
3. Examination of the Cardiovascular System
D. Chest, Cardiovascular and Respiratory Symptoms
1. General Symptoms
2. Chest Wall Symptoms
3. Lung and Pleural Symptoms
4. Cardiovascular Symptoms

E. Chest, Cardiovascular and Respiratory Signs
1. Chest Wall Signs
2. Lung, Pleura, and Respiratory Signs
3. Cardiovascular Signs
4. Mid-Precordial Systolic Murmurs
5. Apical Systolic Murmurs
6. Basal Diastolic Murmurs
7. Mid-Precordial Diastolic Murmur
8. Apical Diastolic Murmurs
9. Pulse Contour
10. Pulse Volume
11. Arterial Sounds
12. Venous Signs of Cardiac Action
F. Chest, Cardiovascular and Respiratory Syndromes
1. Chest Wall Syndromes

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Contents

2.

3.
4.
5.
6.

Respiratory Syndromes
Cardiovascular Syndromes
Myocardial Ischemia Six-Dermatome Pain Syndromes
Inflammatory Six-Dermatome Pain Syndromes
Mediastinal and Vascular Six-Dermatome Pain
Syndromes
7. Gastrointestinal Six-Dermatome Pain Syndromes
8. Pulmonary Six-Dermatome Pain Syndromes

SECTION 2
The Breasts
A. Breast Physiology
1. The Female Breast
2. The Male Breast
B. Superficial Anatomy of the Breasts
C. Physical Examination of the Breasts
1. Breast Examination
2. Nipple Examination
D. Breast Symptoms
E. Breast Signs
F. Breast Syndromes
1. The Female Breast
2. The Male Breast

9. The Abdomen, Perineum, Anus, and Rectosigmoid

A. Major Systems and Their Physiology
1. Alimentary System
2. Hepatobiliary and Pancreatic System
3. Spleen and Lymphatics
4. Kidneys, Ureters, and Bladder
B. Superficial Anatomy of the Abdomen and Perineum
1. The Abdomen
2. The Anus
3. The Rectum
4. The Sigmoid and Descending Colon
C. Physical Examination of the Abdomen
1. The Abdomen
2. Examination of the Perineum, Anus, Rectum,
and Distal Colon
3. Examination of the Anus
4. Examination of the Rectum
5. Examination of the Sigmoid Colon
D. Abdominal, Perineal and Anorectal Symptoms

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xvi

Contents

1. General Symptoms
2. Site-Attributable Symptoms
E. Abdominal, Perineal and Anorectal Signs
1. Abdominal Signs
2. Perineal, Anal, and Rectal Signs
F. Abdominal, Perineal and Anorectal Syndromes
1. GI, Hepatobiliary and Pancreatic Syndromes
2. Perineal, Anal, and Rectal Syndromes
3. Occult GI Blood Loss

10. The Urinary System
A. Overview and Physiology of The Urinary System
B. Anatomy of the Urinary System
C. Physical Examination of the Urinary System
D. Urinary System Symptoms
E. Urinary System Signs
F. Urinary System Syndromes

11. The Female Genitalia and Reproductive System
A. Overview of Female Reproductive Physiology
B. Anatomy of the Female Genitalia and Reproductive System
C. Physical Examination of the Female Genitalia and
Reproductive System

1. The Female Pelvic Examination
D. Female Genital and Reproductive Symptoms
1. General Symptoms
2. Vulvar and Vaginal Symptoms
E. Female Genital and Reproductive Signs
1. Vulvar Signs
2. Vaginal Signs
3. Cervical Signs
4. Uterine Signs
5. Adnexal Signs
6. Rectal Signs
F. Female Genital and Reproductive Syndromes

12. The Male Genitalia and Reproductive System
A. Overview of Male Reproductive Physiology
B. Anatomy of the Male Reproductive System
1. The Penis
2. The Scrotum

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Contents

3. Testis, Epididymis, Vas Deferens, and Spermatic
Cord
4. The Prostate and Seminal Vesicles
C. Physical Examination of the Male Genitalia and
Reproductive System
1. Examination of the Penis
2. Examination of the Scrotum
3. Examination of Scrotal Contents
4. Examination for Scrotal Hernia
5. Examination of the Testes
6. Examination of the Epididymis
7. Examination of the Spermatic Cord
8. Examination of the Inguinal Regions for Hernia
D. Male Genital and Reproductive Symptoms
E. Male Genital and Reproductive Signs
1. Penis Signs
2. Urethral Signs
3. Scrotum Signs
4. Testis, Epididymis, and Other Intrascrotal Signs
5. Prostate and Seminal Vesicle Signs
F. Male Genital and Reproductive Syndromes

13. The Spine, Pelvis and Extremities
A. Major Systems and Their Physiology
1. Bones and Ligaments
2. Joints
3. Muscles, Tendons, and Bursae

B. Superficial Anatomy of the Spine and Extremities
1. The Axial Skeleton: Spine and Pelvis
2. Appendicular Skeleton Including Joints, Ligaments,
Tendons, and Soft Tissues
C. Physical Examination of the Spine and Extremities
1. Examination of the Axial Skeleton: Spine and Pelvis
2. Examination of the Appendicular Skeleton Including
Joints, Ligaments, Tendons, and Soft Tissues
D. Musculoskeletal and Soft Tissue Symptoms
E. Musculoskeletal and Soft Tissue Signs
1. General Signs
2. Axial Musculoskeletal Signs
3. Appendicular Skeleton, Joint, Ligament, Tendon, and
Soft-Tissue Signs
4. Muscle Signs

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Contents

F. Musculoskeletal and Soft Tissue Syndromes
1. General Syndromes
2. Conditions Primarily Affecting Joints
3. Conditions Primarily Affecting Bone
4. Axial Skeleton: Spine and Pelvis Syndromes
5. Appendicular Skeletal Syndromes (Including Joints,
Tendons, Ligaments, and Soft Tissues)
6. Muscle Syndromes

14. The Neurologic Examination
A. Overview of the Nervous System
1. Anatomic Organization
2. Functional Organization of the Nervous System
B. Superficial Anatomy of the Nervous System
C. The Neurologic Examination
1. Cranial Nerve Examination
2. Motor Examination
3. Examination of Reflexes
4. Posture, Balance, and Coordination:
The Cerebellar Examination
5. Testing Specific Peripheral Nerves
6. Movements of Specific Muscles and Nerves
D. Neurologic Symptoms
1. General Symptoms
2. Cranial Nerve Symptoms
3. Motor Symptoms
4. Posture, Balance, and Coordination Symptoms
5. Sensory Symptoms
E. Neurologic Signs

1. Cranial Nerve Signs
2. Motor Signs
3. Reflex Signs
4. Posture, Balance, and Coordination Signs:
Cerebellar Signs
5. Sensory Signs
6. Autonomic Nervous System Signs
7. Some Peripheral Nerve Signs
F. Neurologic Syndromes
1. Falling
2. Headache
3. Seizures

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Contents

4. Impaired Consciousness
5. Chronic Vegetative and Minimally Conscious
States
6. Cerebrovascular Syndromes
7. Other CNS Syndromes

8. Other Motor and Sensory Syndromes
9. Disorders of Language and Speech
10. Syndromes of Impaired Mentation
11. Other Syndromes

15. The Mental Status, Psychiatric, and Social Evaluations

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748
748
751
755
760
761
763

766

SECTION 1
The Mental Status and Phychiatric Evaluation
A. The Mental Status Evaluation
B. Psychiatric Symptoms and Signs
1. Abnormal Perception
2. Abnormal Affect and Mood
3. Abnormal Thinking
4. Abnormal Memory
5. Abnormal Behaviors
C. Psychiatric Syndromes

1. Multiaxial Assessment
2. Acute and Subacute Confusion
3. Anxiety Disorders
4. Disorders of Mood
5. Personality Disorders
6. Other Personality Disorders
7. Thought Disorders
8. Other Disorders

767
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775
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776
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778
780
783
784

SECTION 2
The Social Evaluation
A. Evaluation of Social Function and Risk

B. Common Social Syndromes and Problems

784
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785

PART 3
PREOPERATIVE EVALUATION
16. The Preoperative Evaluation
A. Introduction to Preoperative Screening
B. The History

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xx

Contents

1. Assessment of Cardiovascular and Pulmonary Risk
from History
2. Assessment of Bleeding Risk from History
3. Assessment of Metabolic Risk: Diabetes, Renal, and
Hepatic Insufficiency
4. Family History
5. Medications
6. Personal Habits
7. Mechanical and Positioning Risks

C. The Physical Examination
D. Mental Status
E. Laboratory Tests
F. Summative Risk Assessment

789
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791
792
792
792
793
793
794

PART 4
USE OF THE LABORATORY AND
DIAGNOSTIC IMAGING
17. Principles of Diagnostic Testing
A. Principles of Laboratory Testing
1. Principles of Testing for Disease
2. Aids in the Selection and Interpretation of Tests
3. Examples
4. 2 × 2 Tables Revisited: Caveat Emptor
5. Rule In; Rule Out
6. Summary
B. Principles of Diagnostic Imaging

18. Common Laboratory Tests
A. Blood Chemistries
B. Hematologic Data
1. Blood Cells
2. Coagulation
C. Urinalysis
D. Cerebrospinal Fluid
E. Serous Body Fluids
Index

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843

PREFACE

To The Reader:
Pray thee, take care, that tak’st my book in hand
To read it well: that is to understand.
—Ben Jonson
Far beyond being a text describing how to perform a history and physical exam,
DeGowin’s Diagnostic Examination is, uniquely, a text to assist clinicians in thinking about symptoms and physical signs to facilitate generation of reasonable,
testable diagnostic hypotheses. The clinician’s goal in performing a history and
physical examination is to generate these diagnostic hypotheses. This was true for
Hippocrates and Osler and remains true today. The practice of medicine would
be simple if each symptom or sign indicated a single disease. There are enormous
numbers of symptoms and signs (we cover several hundred) and they can occur
in a nearly infinite number of combinations and temporal patterns. These symptoms and signs are the rough fibers from which the clinician must weave a clinical
narrative, anatomically and pathophysiologically explicit, forming the diagnostic
hypotheses. To master the diagnostic process, a clinician must have four essential
attributes:
(1)
(2)

(3)

(4)

Knowledge: Familiarity with the pathophysiology, symptoms, and signs of
common and unusual diseases.
Skill: The ability to take an accurate and complete history and perform
an appropriate physical examination to elicit the pattern of symptoms and

signs from each patient.
Experience: Comprehensive experience with many diseases and patients,
each thoroughly evaluated, allows the skilled clinician to generate a probabilistic differential diagnosis, a list of those diseases or conditions most
likely to be causes of this patient’s illness.
Judgment: Knowledge of medical science and the medical literature combined with experience reflected upon hones the judgment necessary to
know when and how to test these hypotheses with appropriate laboratory
tests or clinical interventions [Reilly BM. Physical examination in the care of
medical inpatients: an observational study. Lancet. 2003;362:1100–1105].

DeGowin’s Diagnostic Examination has been used by students and clinicians for
over 40 years precisely because of its usefulness in this diagnostic process:
(1)
(2)

It describes the techniques for obtaining a complete history and performing
a thorough physical examination.
It links symptoms and signs with the pathophysiology of disease.

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(3)
(4)

Preface

It presents an approach to differential diagnosis, based upon the pathophysiology of disease, which can be efficiently tested in the laboratory.
It does all of this in a format that can be used as a quick reference at the

“point of care” and as a text to study the principles and practice of history
taking and physical examination.

In undertaking this ninth edition of a venerable classic, my goal is once again
to preserve the unique strengths of previous editions, while adding recent information and references, reducing redundancy and improving clarity. The second
edition is one of the few books I have retained from medical school, 35 years ago.
The reason is that DeGowin’s Diagnostic Examination emphasizes the unchanging
aspects of clinical medicine—the symptoms and signs of disease as related by the
patient and discovered by physical examination.
Pathophysiology links the patient’s story of their illness (the history), the physical signs of disease, and the changes in biologic structure and function revealed
by imaging studies and laboratory testing. Patients describe symptoms, we need
to hear pathophysiology; we observe signs, we need to see pathophysiology; the
radiologist and laboratories report findings, we need to think pathophysiology.
Understanding pathophysiology gives us the tools to understand disease as alterations in normal physiology and anatomy and illness as the patient’s experience
of these changes.
A discussion of pathophysiology (highlighted in blue) occurs after many subject headings. The discussions are brief and included when they assist understanding the symptom or sign. Readers are encouraged to consult physiology
texts to have a full understanding of normal and abnormal physiology [Guyton
AC, Hall JE. Textbook of Medical Physiology. 10th ed. Philadelphia: W.B. Saunders Company: 2000. Lingappa VR, Farey K. Physiological Medicine: A Clinical
Approach to Basic Medical Physiology. New York, NY: McGraw-Hill; 2000]. In
addition, each chapter discusses common syndromes associated with that body
region, to provide you with a sense of the common and uncommon but serious
disease patterns.
DeGowin’s Diagnostic Examination is organized as a useful bedside guide to
assist diagnosis. Part I introduces the conceptual framework for the diagnostic
process in Chapter 1, the essentials of history taking and documentation in Chapter 2, and the screening physical examination in Chapter 3. Part I and Chapter
17, which introduces the principles of diagnostic testing, should be read and
understood by every clinician.
Part II, Chapters 4 through 14, forms the body of the book. Two introductory
chapters discuss the vital signs (Chapter 4) and major physiologic systems that do
not have a primary representation in a single body region (Chapter 5). Chapters

6 to 14 are organized around the body regions sequentially examined during the
physical examination and each has a common structure outlined in the Introduction and User’s Guide. To avoid duplication, the text is heavily cross-referenced.
I hope the reader will find this useful and not too cumbersome.
References to articles from the medical literature are included in the body of
the text. We have chosen articles that provide useful diagnostic information including excellent descriptions of diseases and syndromes, thoughtful discussions
of the approach to differential diagnosis and evaluation of common and unusual
clinical problems, and, in some cases, photographs illustrating key findings. Most
references are from the major general medical journals, the New England Journal
of Medicine, the Lancet, the Annals of Internal Medicine, and the Journal of the


Preface

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American Medical Association. This implies that a clinician who regularly studies these journals will keep abreast of the broad field of medical diagnosis. Some
references are dated in their recommendations for laboratory testing and treatment; they are included because they give thorough descriptions of the relevant
clinical syndromes, often with excellent discussions of the approach to differential diagnosis. Tests and treatments come and go, but good thinking has staying
power. The reader must always check current resources before initiating a laboratory evaluation or therapeutic program.
Evidence-based articles on the utility of the physical exam are included, mostly
from the Rational Clinical Examination series published over the last 15 years
in the Journal of the American Medical Association. They are included with the
caveat that they evaluate the physical exam as a hypothesis-testing tool, not as a hypothesis generating task; their emphasis on transforming the qualitative hypothesis generating task of the history and physical examination into a quantitative
hypothesis testing task is misguided [Feinstein AR. Clinical Judgement revisited:
the distraction of quantitative models. Ann Intern Med. 1994;120:799–805].
Each chapter was independently reviewed by faculty members of the University of Iowa Roy J. and Lucille A. Carver College of Medicine. Their feedback
and assistance is gratefully acknowledged. Reviewers for this edition are Hillary
Beaver MD, Associate Professor Clinical Ophthalmology (Chapter 7); Jane Engeldinger, MD, Professor, Clinical Obstetrics and Gynecology (Chapters 10 and
11); John Lee, MD, Assistant Professor, Department of Otolaryngology (Chapter 7); Christopher J. Goerdt, MD, MPH, Associate Professor, Clinical Internal
Medicine, Division of General Internal Medicine (Chapters 1–3, 16, and 17); Vicki

Kijewski, MD, Assistant Professor of Clinical Psychiatry and Internal Medicine
(Chapter 15); Victoria Jean Allen Sharp, MD, MBA, Clinical Associate Professor,
Departments of Urology and Family Medicine (Chapters 10 and 12); William
B. Silverman, MD, Professor, Clinical Internal Medicine, Division of Gastroenterology and Hepatobiliary Diseases (Chapter 9); Haraldine A. Stafford, MD,
PhD, Associate Professor, Clinical Internal Medicine, Division of Rheumatology
(Chapter 13); Marta Vanbeek, MD, MPH, Clinical Assistant Professor, Department of Dermatology (Chapter 6); and Michael Wall, MD, Professor of Neurology
and Ophthalmology (Chapters 7 and 14).
For the first time color photographs are included to supplement the drawings.
Dr. Hillary Beaver supplied the eye and fundus photographs, courtesy of the
University of Iowa Department of Ophthalmology. The other photos were taken
by the author (RFL) in his office practice.
Once again, Mr. Shawn Roach has done an excellent job of revising many of the
illustrations for this edition. I greatly appreciate his patience and cooperation.
Mrs. Denise Floerchinger was instrumental in coordinating my schedule and
keeping me on task. Her support in this and my many other projects and clinical
activities is essential to my success and is gratefully acknowledged.
My co-authors for this edition, Donald D. Brown, MD, and Richard L. DeGowin, MD, have been instrumental in seeing that the ninth edition maintains
the strengths of previous editions. Dr. Brown directed the history taking and
physical examination course at the University of Iowa for over 25 years. He is
annually nominated for best teacher awards by the students in recognition of
his knowledge and enthusiasm for teaching these essential skills. As a practicing
cardiologist, he is the primary editor for Chapters 8 and 16.
I am especially thankful for the continuing contributions and encouragement
of Dr. Richard L. DeGowin during the extensive revisions for eighth edition and


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Preface

preparations for this ninth edition. He is a wonderful colleague and friend to
whom I am ever thankful for the opportunity to edit this edition of DeGowin’s
Diagnostic Examination.
Mr. James Shanahan, our editor at McGraw-Hill, has been actively involved
from the beginning in the planning and execution of the ninth edition. His
encouragement and support are deeply appreciated. The McGraw-Hill editorial
and publishing staff under his direction, especially Samir Roy, have been prompt
and professional throughout manuscript preparation, editing, and production.
I wish to thank my colleagues who have encouraged me throughout the course
of this project. I have incorporated many suggestions from my co-authors and
each of the reviewers; any remaining deficiencies are mine. Ultimately, you, the
reader, will determine the strengths and weaknesses of this edition. I welcome your
feedback and suggestions. Email your comments to
(please include “DeGowin’s” on the subject line).
Richard F. LeBlond, MD, MACP
Iowa City, Iowa