Ebook Macleod''s clinical examination: Part 1

Macleod’s
Clinical
Examination


John Macleod
(1915–2006)
John Macleod was appointed consultant physician at
the Western General Hospital, Edinburgh, in 1950. He
had major interests in rheumatology and medical education. Medical students who attended his clinical teaching sessions remember him as an inspirational teacher
with the ability to present complex problems with great
clarity. He was invariably courteous to his patients and
students alike. He had an uncanny knack of involving
all students equally in clinical discussions and used
praise rather than criticism. He paid great attention to
the value of history taking and, from this, expected
students to identify what particular aspects of the physical examination should help to narrow the diagnostic
options.
His consultant colleagues at the Western welcomed
the opportunity of contributing when he suggested
writing a textbook on clinical examination. The book
was irst published in 1964 and John Macleod edited
seven editions. With characteristic modesty he was very
embarrassed when the eighth edition was renamed
Macleod’s Clinical Examination. This, however, was a
small way of recognising his enormous contribution
to medical education.
He possessed the essential quality of a successful
editor – the skill of changing disparate contributions
from individual contributors into a uniform style and

format without causing offence; everybody accepted
his authority. He avoided being dogmatic or condescending. He was generous in teaching others his editorial skills and these attributes were recognised when he
was invited to edit Davidson’s Principles and Practice of
Medicine.

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Content Development Specialist: Helen Leng
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Edited by

Graham Douglas BSc(Hons) MBChB FRCPE
Consultant Physician
Aberdeen Royal Inirmary
Honorary Reader in Medicine
University of Aberdeen

Fiona Nicol BSc(Hons) MBBS FRCGP FRCP(Edin)
Formerly GP Principal and Trainer
Stockbridge Health Centre, Edinburgh
Honorary Clinical Senior Lecturer
University of Edinburgh

Colin Robertson BA(Hons) MBChB FRCPEd FRCSEd FSAScot

Honorary Professor of Accident and Emergency Medicine
University of Edinburgh

Illustrations by
Robert Britton
Ethan Danielson

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2013

Clinical
Examination

Macleod’s

Thirteenth
edition


© 2013 Elsevier Ltd All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information
storage and retrieval system, without permission in writing from the publisher. Details
on how to seek permission, further information about the publisher’s permissions
policies and our arrangements with organisations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under
copyright by the publisher (other than as may be noted herein).
First edition 1964
Second edition 1967

Third edition 1973
Fourth edition 1976
Fifth edition 1979
Sixth edition 1983
Seventh edition 1986

Eighth edition 1990
Ninth edition 1995
Tenth edition 2000
Eleventh edition 2005
Twelfth edition 2009
Thirteenth edition 2013

ISBN 9780702047282
International ISBN 9780702047299
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Notices
Knowledge and best practice in this ield are constantly changing. As new research
and experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identiied, readers are advised
to check the most current information provided (i) on procedures featured or (ii) by the

manufacturer of each product to be administered, to verify the recommended dose or
formula, the method and duration of administration, and contraindications. It is the
responsibility of practitioners, relying on their own experience and knowledge of their
patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of any
methods, products, instructions, or ideas contained in the material herein.

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Preface
The skills of history taking and physical examination
are central to the practice of clinical medicine. This
book describes these and is intended primarily for
medical undergraduates. It is also of value to primary
care and postgraduate hospital doctors, particularly
those studying for higher clinical examinations or

returning to clinical practice. The book is also an essential reference for nurse practitioners and other paramedical staff who are involved in medical assessment
of patients.
This edition has four sections: Section 1 details the
principles of history taking and general examination;
Section 2 covers symptoms and signs in individual
system examinations; Section 3 reviews speciic situations; and a new Section 4 deals with how to apply these
techniques in an OSCE.
The text has been extensively revised and edited, with
two new chapters on the frail elderly and the febrile
adult. The number of illustrations has been increased
and many have been updated. Line drawings illustrate
surface anatomy and techniques of examination; over
330 photographs show normal and abnormal clinical
appearances.
We recognise the current debate where some decry
clinical examination because of the lack of evidence

supporting many techniques. Where evidence exists,
however, we highlight this in a new feature for this
edition: evidence-based examination boxes (EBEs). We
are convinced of the need to acquire and hone clinical
examination skills to avoid unnecessary expensive and
potentially harmful over-investigation. Nevertheless,
there is a need to evaluate rigorously many clinical
symptoms and signs. It is possible to open this book at
almost any page and ind a topic which cries out for
evidence-based analysis. We continue to hope that the
book will stimulate this enquiry and would encourage these responses and incorporate them in future
editions.
This 13th edition of Macleod’s Clinical Examination –

full text, illustrations and videos – is available in an
online version, as part of Elsevier’s ‘Student Consult’
electronic library. It is closely integrated with Davidson’s
Principles and Practice of Medicine, and is best read in
conjunction with that text.
G.D.
F.N.
C.R.
Edinburgh and Aberdeen
2013

v


Acknowledgements
We are very grateful to all the contributors and editors
of previous editions; in particular, we owe an immeasurable debt to Dr John Munro for his teaching and
wisdom.
We greatly appreciate the constructive suggestions
and help that we have received from past and present
students, colleagues and focus groups in the design and
content of the book.
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: Alessandro Aldera, University of Cape Town;
Sabreen Ali, University of Shefield; Bernard Ho, St
George’s University of London; Edward Tzu-Yu Huang,
University of Birmingham; Emma Jackson, University of
Manchester; Amit Kaura, University of Bristol; Brian

vi

Morrissey, University of Aberdeen; Neena Pankhania,
University of Leicester; Tom Paterson, University of
Glasgow; Christopher Roughley, University of Warwick;
and Christopher Saunders, University of Edinburgh.
We wish to thank the many individuals who have
provided advice and support: Jackie Fiddes for designing the manikins and for her computer skills; Steven
Hill of the Department of Medical Illustration, University of Aberdeen; Jason Powell for his help with
illustrations; Victoria Buchan for her help linking the
examination videos with the online text; Helen Leng
and Laurence Hunter at Elsevier.
G.D.
F.N.
C.R.


Picture and box credits
We are grateful to the following individuals and
organisations for permission to reproduce the igures
and boxes listed below:

Chapter 1
Fig. 1.1 WHO Guidelines on Hand Hygiene in Health
Care First Global Patient Safety Challenge Clean Care
is Safer Care />protection/en/ © World Health Organization 2009.
All rights reserved. Box 1.1 Courtesy of the General
Medical Council (UK).

Chapter 2
Box 2.32 Trzepacz PT, Baker RW, The psychiatric
mental status examination 1993 by permission of
Oxford University Press USA. Box 2.50 Hodkinson
HM, Evaluation of a mental test score for assessment
of mental impairment in the elderly Age and Ageing
1972 1(4): 233-8 by permission of Oxford University
Press.

Chapter 3
Figs 3.19C and 3.28A–D Forbes CD, Jackson WF.
Color Atlas of Clinical Medicine. 3rd edn. Edinburgh:
Mosby; 2003.

Chapter 5
Fig. 5.3 Currie G, Douglas G, eds. Flesh and Bones of
Medicine. Edinburgh: Mosby; 2011.

Chapter 6
Figs 6.6D, 6.16A–D and 6.38A Forbes CD, Jackson WF.
Color Atlas of Clinical Medicine. 3rd edn. Edinburgh:
Mosby; 2003. Fig. 6.6E Colledge NR, Walker BR,
Ralston SH, eds. Davidson’s Principles and Practice of
Medicine. 21st edn. Edinburgh: Churchill Livingstone;
2010. Fig. 6.8C Haslett C, Chilvers ER, Boon NA,
Colledge NR, eds, Davidson’s Principles and Practice
of Medicine, 19th edn. Edinburgh: Churchill
Livingstone; 2002. Box 6.19 Reproduced by kind
permission of the British Hypertension Society.

Chapter 7
Fig. 7.24D Forbes CD, Jackson WF. Color Atlas of
Clinical Medicine. 3rd edn. Edinburgh: Mosby; 2003.
Box 7.7 Reproduced from British Medical Journal
Fletcher CM, Elmes PC, Fairbairn AS et al 2(5147):257
1959 with permission from BMJ Publishing Group Ltd.
Box 7.11 Reproduced from Murray W. Johns. A new
method for measuring daytime sleepiness: the
Epworth Sleepiness Scale, Sleep, 1991; 14(6): 540-545.
ESS contact information and permission to use:
MAPI Research Trust, Lyon, France. E-mail:

Internet: www.
mapi-trust.org. Box 7.17 Reproduced from Thorax
Lim WS 58(5):377 2002 with permission from BMJ
Publishing Group Ltd. Box 7.23 Reproduced from
Wells PS, Anderson DR, Rodger M et al, 2000
Derivation of a Simple Clinical Model to Categorize
Patients Probability of Pulmonary Embolism:
Increasing the Models Utility with the SimpliRED
D-dimer, Thromb Haemost 83(3) 416-420 with
permission from Schattauer Publishers.

Chapter 8
Fig. 8.10 Reproduced by kind permission of Dr K W
Heaton, Reader in Medicine at the University of
Bristol. © 2000 Norgine Pharmaceuticals Ltd.
Figs 8.31A&B and 8.32 Forbes CD, Jackson WF. Color
Atlas of Clinical Medicine. 3rd edn. Edinburgh: Mosby;
2003. Box 8.15 Reproduced by kind permission of the

Rome Foundation. Box 8.20 Reproduced from Journal
of the British Society of Gastroenterology Rockall TA
et al 38(3):316 1996 with permission from BMJ
Publishing Group Ltd. Box 8.34 Reproduced from
Conn HO, Leevy CM, Vlahcevic ZR et al 1977
Comparison of lactulose and neomycin in the
treatment of chronic portal-systemic encephalopathy.
A double blind controlled trial, Gastroenterology
72(4): 573 with permission from Elsevier Inc.
Box 8.47 Reproduced from Pugh RNH, Murray-Lyon
IM, Dawson JL et al Transection of the oesophagus
for bleeding oesophageal varices British Journal of
Surgery 646-649 1973 with permission from John
Wiley and Sons.

Chapter 9
Fig. 9.12 Pitkin J, Peattie AB, Magowan BA. Obstetrics
and Gynaecology: An Illustrated Colour Text.
Edinburgh: Churchill Livingstone; 2003. Box 9.4
Reproduced from Barry MJ, Fowler FJ Jr, O’Leary MP
et al The American Urological Association symptom
index for benign prostatic hyperplasia. The
Measurement Committee of the American Urological
Association. J Urol. 1992 148(5):1549-57. ESS contact
information and permission to use: MAPI Research
Trust, Lyon, France. E-mail: PROinformation@
mapi-trust.org Internet: www.mapi-trust.org

Chapter 11
Fig. 11.15 Epstein O, Perkin GD, de Bono DP, Cookson

J. Clinical Examination. 2nd edn. London: Mosby;
1997. Box 11.18 Medical Research Council scale for
muscle power. Aids to examination of the peripheral
nervous system. Memorandum no 45 London Her
Majesty’s Stationery Ofice 1976 © Crown Copyright.

vii


Chapter 12
Figs 12.15A&B Forbes CD, Jackson WF. Color Atlas
of Clinical Medicine. 3rd edn. Edinburgh: Mosby;
2003. Fig. 12.16 Nicholl D, ed. Clinical Neurology.
Edinburgh: Churchill Livingstone; 2003. Figs 12.27A–D
Epstein O, Perkin GD, de Bono DP, Cookson J. Clinical
Examination. 2nd edn. London: Mosby; 1997.

Chapter 13
Fig. 13.20 Scully C, Oral and Maxillofacial Medicine.
2nd edn. Edinburgh: Churchill Livingstone; 2008.
Figs 13.21A and 13.25B Bull TR. Color Atlas of ENT
Diagnosis. 3rd edn. London: Mosby-Wolfe; 1995.

Chapter 14
Fig. 14.2 Colledge NR, Walker BR, Ralston SH, eds.
Davidson’s Principles and Practice of Medicine.
21st edn. Edinburgh: Churchill Livingstone; 2010.
Fig. 14.9A Forbes CD, Jackson WF. Color Atlas of
Clinical Medicine. 3rd edn. Edinburgh: Mosby; 2003.
Box 14.3 Reproduced from Aletaha D, Neogi T, Silman

AJ et al 2010 Rheumatoid arthritis classiication
criteria: an American College of Rheumatology/
European League Against Rheumatism collaborative
initiative, Arthritis & Rheumatism 2569-2581 with
permission from John Wiley and Sons. Box 14.13
Reproduced from Annals of the rheumatic diseases
Beighton P, Solomon L, Soskolne CL 32(5): 413 1973
with permission from BMJ Publishing Group.

Chapter 15
Figs 15.7, 15.8, 15.11A&B and 15.12 Lissauer T,
Clayden G. Illustrated Textbook of Paediatrics.

viii

2nd edn. Edinburgh: Mosby; 2001. Fig. 15.17 Child
Growth Foundation. Fig. 15.23 Courtesy of Dr Jack
Beattie, Royal Hospital for Sick Children, Glasgow.
Box 15.4 Reproduced with permission of International
Anesthesia Research Society from Current researches
in anesthesia & analgesia Apgar V 32(4) 1953;
permission conveyed through Copyright Clearance
Center, Inc.

Chapter 16
Fig. 16.2 Reproduced from Clarifying Confusion: The
Confusion Assessment Method: A New Method for
Detection of Delirium Inouye SK, vanDyck CH, Alessi
CA et al Annals of Internal Medicine 113 1990 with
permission from the American College of Physicians.

Fig 16.3 Reproduced by kind permission of BAPEN.

Chapter 19
Fig. 19.9 Reproduced with the kind permission of the
Resuscitation Council (UK). Box 19.1 Adapted from
Hillman K, Parr M, Flabouris A et al 2001 Redeining
in-hospital resuscitation: the concept of the medical
emergency team. Resuscitation 48(2): 105-110 with
permission from Elsevier Ltd. Box 19.14 Reproduced
from The Lancet 304(7872), Teasdale G, Jennett B,
Assessment of coma and impaired consciousness: a
practical scale, 81–84, 1974 with permission from
Elsevier Ltd.


How to get the most out of this book
The purpose of this book is to document and explain
how to:
• Talk with a patient
• Take the history from a patient
• Examine a patient
• Formulate your indings into differential diagnoses
• Rank these in order of probability
• Use investigations to support or refute your
differential diagnosis.
Initially, when you approach a section, we suggest that
you glance through it quickly, looking at the headings
and how it is laid out. This will help you to see in your
mind’s eye the framework to use.
Learn to speed-read. It is invaluable in medicine and

in life generally. Most probably, the last lesson you had
on reading was at primary school. Most people can dramatically improve their speed of reading and increase
their comprehension by using and practising simple
techniques.
Try making mind maps of the details to help you
recall and retain the information as you progress through
the chapter. Each of the systems chapters is laid out in
the same order:
• Introduction and anatomy
• Symptoms and deinitions
• The history: what questions to ask and how to
follow them up
• The physical examination: what and how to examine
• Investigations: those done at the patient’s side
(near-patient tests); laboratory investigations;
imaging; and invasive investigations.
Your purchase of the book entitles you to access the
complete text online and to search using key words or
using the index. You can view all the illustrations and
use the hypertext-linked page cross-references to navigate quickly through the book.
Return to this book to refresh your technique if you
have been away from a particular ield for some time. It
is surprising how quickly your technique deteriorates if
you do not use it regularly. Practise at every available
opportunity so that you become proicient at examination techniques and gain a full understanding of the
range of normality.
Ask a senior colleague to review your examination
technique regularly; there is no substitute for this and
for regular practice. Listen also to what patients say – not
only about themselves but also about other health professionals – and learn from these comments. You will

pick up good and bad points that you will want to
emulate or avoid.
Finally, enjoy your skills. After all, you are learning to
be able to understand, diagnose and help people. For
most of us, this is the reason we became doctors.

Boxes and tables
Boxes and tables are a popular way of presenting information and are particularly useful for revision. They are
classiied by the type of information they contain using
the following symbols:

Causes
Clinical features
Investigations
Evidence-based examination
Other information
Evidence-based examination
Evidence-based examination applies the best available
evidence from scientiic method to clinical decision
making and is an increasingly essential part of modern
clinical practice. However, most clinical examination
techniques have developed over generations of medical
practice without rigorous scientiic assessment. To highlight examples where there is evidence-based examination we have included 55 EBE boxes. The art of medicine
depends on being able to combine scientiic rigour with
long-established techniques but this area needs to be
re-evaluated and updated constantly as new information comes to light.

Examination sequences
Throughout the book there are outlines of techniques
that you should follow when examining a patient. These

are identiied with a red heading ‘Examination sequence’.
The bullet-point list provides the exact order to undertake the examination.

To help your understanding of how to perform
these techniques many of the examination sequences
have been ilmed and those marked with the symbol
above can be viewed as part of the Student Consult
online text.

ix


Glasgow Coma Scale videos
The Glasgow Coma Scale (GCS) is the globally accepted
standard means of assessing conscious state. It is validated and reliable. Included as part of the Student
Consult website are two video demonstrations of how
the Scale should be performed in clinical situations:
• using the GCS: how to perform the different
elements of the GCS
• clinical scenarios: using the GCS in a clinical
context.
As well as demonstrating correct techniques, the videos
illustrate common pitfalls in using the GCS and give
guidance on how to avoid these.

Video production team
Writer, narrator, director and producer
Mr Jacques Kerr

Nurses

Dr Sharon Mulhern
Mr Jacques Kerr

Patient
Stevie Allen

Production
Mirage Television Productions
For more information see www.practicalgcs.com

x


Clinical skills videos
By logging on to the Student Consult website you will
have access to clinical examination videos, custommade for this textbook. Filmed using qualiied doctors,
with hands-on guidance from the authorship team,
and narrated by one of the editors, Professor Colin
Robertson, these videos offer you the chance to watch
trained professionals performing many of the examination routines described in the book. By helping you to
memorise the essential examination steps required for
each major system and by demonstrating the proper
clinical technique, these videos should act as an important bridge between textbook learning and bedside
teaching. The videos will be available for you to view
again and again as your clinical skills develop and will
prove invaluable as you prepare for your clinical OSCE
examinations.

Each examination routine has a detailed explanatory
narrative but for maximum beneit view the videos in

conjunction with the book. To facilitate this, sections of
the videos are also linked to the online text, thus allowing you to view the relevant examination sequences as
you progress through each chapter.

Video contents
•
•
•
•
•
•
•

Examination of
Examination of
Examination of
Examination of
Examination of
Examination of
Examination of

the cardiovascular system
the respiratory system
the gastrointestinal system
the neurological system
the ear
the musculoskeletal system
the thyroid gland

Video production team

Director and editor
Dr Iain Hennessey

Producer
Dr Alan Japp

Sound and narrator
Professor Colin Robertson
Dr Nick Morley

Clinical examiners
Dr Amy Robb
Dr Ben Waterson

Patients
Abby Cooke
Omar Ali
xi


Contributors
Elaine Anderson MD FRCS(Ed)

Colin Duncan MD FRCOG

Clinical Director, Breast and Plastics, NHS Lothian;
Consultant Breast Surgeon, Western General Hospital,
Edinburgh

Senior Lecturer in Reproductive Medicine, Consultant

Gynaecologist, University of Edinburgh

John Bevan BSc(Hons) MBChB(Hons) MD FRCPE
Consultant Endocrinologist, Aberdeen Royal Inirmary;
Honorary Professor of Endocrinology, University of
Aberdeen

Andrew Bradbury BSc MB ChB(Hons) MD MBA FRCS(Ed)
Sampson Gamgee Professor of Vascular Surgery, and
Director of Quality Assurance and Enhancement,
College of Medical and Dental Sciences, University of
Birmingham; Consultant Vascular and Endovascular
Surgeon, Heart of England NHS Foundation Trust,
Birmingham

Consultant in Acute Medicine for the Elderly and
Honorary Senior Lecturer, Western General Hospital,
Edinburgh and University of Edinburgh

Rebecca Ford MEd MRCP MRCS(Edin) FRCOphth
Consultant Ophthalmologist, Aberdeen Royal
Inirmary

David Gawkrodger

DSc MD FRCP FRCPE

Consultant Dermatologist, Royal Hallamshire Hospital,
Shefield; Honorary Professor of Dermatology,
University of Shefield

Gareth Clegg MB ChB BSc(Hons) MRCP PhD FCEM

Jane Gibson BSc(Hons) MD FRCPE FSCP(Hon)

Senior Clinical Lecturer, University of Edinburgh;
Honorary Consultant in Emergency Medicine, Royal
Inirmary of Edinburgh

Consultant Rheumatologist, Fife Rheumatic Diseases
Unit, NHS Fife, Kirkcaldy, Fife; Honorary Senior
Lecturer, University of St Andrews

Nicki Colledge BSc(Hons) FRCPE

Neil Grubb BSc(Hons) MBChB MRCP MD

Consultant Physician in Medicine for the Elderly,
Liberton Hospital and Royal Inirmary of Edinburgh;
Honorary Senior Lecturer, University of Edinburgh

Consultant Cardiologist and Electrophysiologist,
Edinburgh Heart Centre, Royal Inirmary of
Edinburgh; Honorary Senior Lecturer, University of
Edinburgh

Allan Cumming MBChB MD FRCPE
Dean of Students, College of Medicine and Veterinary
Medicine, University of Edinburgh

Richard Davenport DM FRCPE
Consultant Neurologist, Western General Hospital and
Royal Inirmary of Edinburgh; Honorary Senior
Lecturer, University of Edinburgh

Graham Devereux MA MD PhD FRCPE
Professor of Respiratory Medicine, University of
Aberdeen; Honorary Consultant Physician, Aberdeen
Royal Inirmary, Aberdeen

Graham Douglas BSc(Hons) MBChB FRCPE
Consultant Physician, Aberdeen Royal Inirmary;
Honorary Reader in Medicine, University of Aberdeen

Jamie Douglas BSc MedSci MBChB MRCGP
General Practitioner, Albion Medical Practice, Ashton
Under Lyne, Lancashire

xii

Andrew Elder BSc MBChB FRCPE FRCPSG FRCP

Iain Hennessey MBChB(Hons) BSc(Hons) MRCS MMIS
Specialty Trainee in Paediatric Surgery, Alder Hey
Children’s Hospital, Liverpool

James Huntley MA MCh DPhil FRCPE FRCS(Glas)
FRCS(Edin)(Tr&Orth)

Consultant Orthopaedic Surgeon, Royal Hospital for

Sick Children, Yorkhill; Honorary Clinical Associate
Professor, University of Glasgow

John Iredale DM FRCP FMedSci FRSE
Professor of Medicine, Director MRC Centre for
Inlammation Research, Dean of Clinical Medicine,
Queen’s Medical Research Institute, University of
Edinburgh

Alan Japp

MBChB(Hons) BSc(Hons) MRCP

Cardiology Registrar, Royal Inirmary of Edinburgh

Jacques Kerr BSc MB BS FRCS FCEM
Consultant in Emergency Medicine and Clinical Lead,
Department of Emergency Medicine, Borders General
Hospital, Melrose


Robert Laing MD FRCPE

Stephen Payne MS FRCS FEB(Urol)

Consultant Physician in Infectious Diseases, Aberdeen
Royal Inirmary; Honorary Clinical Senior Lecturer,
University of Aberdeen

Consultant Urological Surgeon, Central Manchester

Foundation Trust, Manchester

Andrew Longmate MBChB FRCA FFICM

Stephen Potts MA FRCPsych

Consultant Anaesthetist, Forth Valley Royal Hospital,
Larbert, Stirlingshire

Consultant Psychiatrist, Department of Psychological
Medicine, Royal Inirmary of Edinburgh: Honorary
Senior Clinical Lecturer, University of Edinburgh

Elizabeth MacDonald FRCPE

Colin Robertson BA(Hons) MBChB FRCPEd FRCSEd FSAScot

Consultant Physician in Medicine of the Elderly,
Western General Hospital, Edinburgh

Honorary Professor of Accident and Emergency
Medicine, University of Edinburgh

Alastair MacGilchrist MD FRCPE FRCPS(Glas)

Laura Robertson BMedSci(Hons) MBBS FRCA

Consultant Gastroenterologist/Hepatologist, Royal
Inirmary of Edinburgh

Specialty trainee in Anaesthesia, Western Inirmary of
Glasgow

Hadi Manji MA MD FRCP(Lond)

David Snadden MBChB MCISc MD FRCGP FRCP(Edin) CCFP

Consultant Neurologist and Honorary Senior Lecturer,
National Hospital for Neurology and Neurosurgery,
London

Professor of Family Practice and Executive Associate
Dean Education, Faculty of Medicine, University of
British Columbia, Canada

Nicholas Morley MA (Cantab) MBChB MRCSEd FRCR

James C Spratt BSc MBChB MD FRCP FESC FACC

Clinical Lecturer in Radiology, Edinburgh Cancer
Research UK Centre, University of Edinburgh

Consultant Cardiologist, Forth Valley Royal Hospital,
Larbert, Stirlingshire

Dilip Nathwani MBChB FRCP(Ed;Glas;Lond) DTM&H

Ben Stenson MD FRCPCH FRCPE

Consultant Physician and Honorary Professor of

Infection, Ninewells Hospital and Medical School,
Dundee

Consultant Neonatologist, Simpson Centre for
Reproductive Health, Royal Inirmary of Edinburgh;
Honorary Professor of Neonatology, University of
Edinburgh

Fiona Nicol BSc(Hons) MBBS FRCGP FRCP(Edin)
Formerly GP Principal and Trainer, Stockbridge Health
Centre, Edinburgh; Honorary Clinical Senior Lecturer,
University of Edinburgh

Jane Norman MD FRCOG F Med Sci
Professor of Maternal and Fetal Health, Consultant
Obstetrician, University of Edinburgh

Kum Ying Tham MBBS FRCS(Ed) MSc
Consultant, Emergency Department, Tan Tock Seng
Hospital; Assistant Dean, Lee Kong Chian School of
Medicine, Singapore

Steve Turner MBBS MD MRCP(UK) FRCPCH

John Olson MD FRCPE FRCOphth

Senior Clinical Lecturer in Child Health, University of
Aberdeen; Honorary Consultant Paediatrician, Royal
Hospital for Sick Children, Aberdeen

Consultant Ophthalmic Physician, Aberdeen Royal
Inirmary; Honorary Reader, University of Aberdeen

Janet Wilson MD FRCS(Ed) FRCS(Eng) FRCSLT(Hon)

Paul O’Neill MD FRCP(Lond)
Professor of Medical Education, University of
Manchester and Honorary Consultant Physician,
UHSM NHS Foundation Trust, Manchester

Professor of Otolaryngology Head and Neck Surgery,
University of Newcastle; Honorary Consultant
Otolaryngologist, Freeman Hospital, Newcastle
upon Tyne

Rowan Parks MD FRCSI FRCS(Edin)
Professor of Surgical Sciences and Honorary
Consultant Surgeon, Royal Inirmary of Edinburgh

xiii


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Advisory board
We are proud that Macleod’s Clinical Examination is regularly consulted by a range of health professionals and at
a variety of levels in their training. It is our wish that
the content is regarded as accurate and appropriate
by all our readers. To ensure this aim, this latest edition

has beneited from detailed advice from an Advisory
Board comprising students and junior doctors, as well
as representatives from the nursing and ambulance professions, primary care and the academic community.
Signiicant changes have resulted as a direct result of
this invaluable input.
Macleod’s international reputation has grown with
each edition and as editors we receive and value the
feedback from our global readership. To ensure we take
full account of the variations of international curricula
we have recruited representatives from key geographical areas to the Advisory Board whose detailed comments and critical appraisal have been of great help in
shaping the content of this new edition.
We acknowledge the enthusiasm and support of all
our Advisory Board members and thank them for contributing to this edition. We have listed their details at
the time that they reviewed the book.

UK advisory board
Graeme Finnie, Medical Student, University of
Aberdeen
Paul Gowens, Head of Clinical Governance and
Quality, Scottish Ambulance Service, Dunfermline
Mike Greaves, Professor and Head of School of
Medicine and Dentistry, University of Aberdeen
Chris Grifiths, Professor of Primary Care, Barts and
The London School of Medicine and Dentistry, London
Kate Haslett, Specialty trainee in Oncology, Glasgow
Jayne Langran, Clinical Educator/Chest Pain Nurse
Specialist, Coronary Care Unit, Raigmore Hospital,
Inverness

Anthea Lints, Professor and Director of Postgraduate

General Practice Education, South East Scotland
Deanery, Edinburgh
Will Muirhead, Foundation Year 1 Doctor, Queen’s
Medical Centre, Nottingham
Sarah Richardson, Medical Student, University of
Edinburgh
Laura Robertson, Specialty Registrar in Anaesthetics,
Glasgow
Gordon Stewart, Professor, Department of Medicine,
University College London

International advisory board
Wael Abdulrahman Almahmeed, Consultant
Cardiologist and Head of the Division of Cardiology,
Shaikh Khalifa Medical City, Abu Dhabi, United Arab
Emirates
Maaret Castrén, Professor in Emergency Medicine,
Department of Clinical Science and Education,
Karolinska Institute, Stockholm, Sweden
Jyothi Mariam Idiculla, Associate Professor,
Department of Internal Medicine, St John’s Medical
College, Bangalore, India
Shubhangi Kanitkar, Professor of Medicine, Dr D.Y.
Patil Medical College and Hospital, Pune, India
Kar Neng Lai, Yu Chiu Kwong Chair of Medicine,
Department of Medicine, University of Hong Kong,
Hong Kong
Kum-Ying Tham, Consultant Emergency Physician,
Tan Tock Seng Hospital and Clinical Associate
Professor, Yong Loo Lin School of Medicine, National

University of Singapore, Singapore

xv


Contents
SECTION 1 HISTORY TAKING AND GENERAL EXAMINATION
1 Approach to the patient. . . . . . . . . . . . . . . . . . . . . . . . . . 1
Colin Robertson, Fiona Nicol, Graham Douglas

2 History taking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
David Snadden, Robert Laing, Stephen Potts, Fiona Nicol, Nicki Colledge

3 The general examination . . . . . . . . . . . . . . . . . . . . . . . . 41
Graham Douglas, John Bevan

SECTION 2 SYSTEM EXAMINATION
4 The skin, hair and nails . . . . . . . . . . . . . . . . . . . . . . . . . 63
David Gawkrodger

5 The endocrine system . . . . . . . . . . . . . . . . . . . . . . . . . 77
John Bevan

6 The cardiovascular system . . . . . . . . . . . . . . . . . . . . . . . 97
Neil Grubb, James Spratt, Andrew Bradbury

7 The respiratory system . . . . . . . . . . . . . . . . . . . . . . . . .137
Graham Devereux, Graham Douglas

8 The gastrointestinal system. . . . . . . . . . . . . . . . . . . . . . .165

Alastair MacGilchrist, John Iredale, Rowan Parks

9 The renal system . . . . . . . . . . . . . . . . . . . . . . . . . . . .195
Allan Cumming, Stephen Payne

10 The reproductive system . . . . . . . . . . . . . . . . . . . . . . . .211
Elaine Anderson, Colin Duncan, Jane Norman, Stephen Payne

11 The nervous system . . . . . . . . . . . . . . . . . . . . . . . . . .239
Richard Davenport, Hadi Manji

12 The visual system . . . . . . . . . . . . . . . . . . . . . . . . . . .275
John Olson, Rebecca Ford

13 The ear, nose and throat . . . . . . . . . . . . . . . . . . . . . . . .297
Janet Wilson, Fiona Nicol

14 The musculoskeletal system . . . . . . . . . . . . . . . . . . . . . .315
Jane Gibson, James Huntley

xvi


SECTION 3 EXAMINATION IN SPECIFIC SITUATIONS
15 Babies and children. . . . . . . . . . . . . . . . . . . . . . . . . . .355
Ben Stenson, Steve Turner

16 The frail elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . .379
Andrew Elder, Elizabeth MacDonald

17 The febrile adult . . . . . . . . . . . . . . . . . . . . . . . . . . . .391
Dilip Nathwani, Kum Ying Tham

18 Assessment for anaesthesia and sedation . . . . . . . . . . . . . . .401
Laura Robertson, Andrew Longmate

19 The critically ill . . . . . . . . . . . . . . . . . . . . . . . . . . . . .411
Gareth Clegg, Colin Robertson

20 Conirming death . . . . . . . . . . . . . . . . . . . . . . . . . . . .423
Jamie Douglas, Graham Douglas

SECTION 4 ASSESSING CLINICAL EXAMINATION TECHNIQUE
21 OSCEs and other examination formats . . . . . . . . . . . . . . . . .427
Paul O’Neill

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441

xvii


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SECTION 1 HISTORY TAKING AND GENERAL EXAMINATION

Colin Robertson
Fiona Nicol
Graham Douglas

Approach to
the patient
Being a ‘good’ doctor 2

Communication skills 3

Conidentiality and consent 2

Expectations and respect 3

Personal responsibilities 3

Hand washing and cleanliness 3

1

Dress and demeanour 3

1


APPROACH TO THE PATIENT

1

BEING A ‘GOOD’ DOCTOR
From your irst day as a student you have professional
obligations placed upon you by the public, the law
and your colleagues which continue throughout your
working life. Patients want more than merely intellectual and technical proiciency. To be a good doctor or

nurse it is much easier if you genuinely like and are
interested in people. Most patients want a doctor who
listens to them and over 70 separate qualities have been
listed as being important. Fundamentally, though, we all
want doctors who:
• are knowledgeable
• respect people, healthy or ill, regardless of who
they are
• support patients and their loved ones when and
where needed
• always ask courteous questions, let people talk and
listen to them carefully
• promote health as well as treat disease
• give unbiased advice, let people participate actively
in all decisions related to their health and
healthcare, assess each situation carefully and help
whatever the situation
• use evidence as a tool, not as a determinant of
practice
• humbly accept death as an important part of life;
and help people make the best possible
arrangements when death is close
• work cooperatively with other members of the
healthcare team
• are proactive advocates for their patients, mentors
for other health professionals and ready to learn
from others, regardless of their age, role or status.
Doctors also need a balanced life and to care for themselves and their families. In short, we want doctors who
are happy and healthy, caring and competent, and who
care for people throughout their life.

One way to reconcile these expectations with your
inexperience and incomplete knowledge or skills is to
put yourself in the situation of the patient and/or relatives. Consider how you would wish to be cared for
in the patient’s situation, acknowledging that you are
different and your preferences may not be the same.
Most clinicians approach and care for patients differently once they have their own or a relative’s experience
as a patient. Doctors, nurses and everyone involved in
healthcare have a profound inluence on how patients
experience illness and their sense of dignity. When you
are dealing with patients, always consider your:
• A: attitude – how would I feel in this patient’s
situation?
• B: behaviour – always treat patients with kindness
and respect
• C: compassion – recognise the human story that
accompanies each illness
• D: dialogue – listen to and acknowledge the patient.

CONFIDENTIALITY AND CONSENT
2

As a student and as a doctor or nurse you will be given
private and intimate information about patients and

1.1 The duties of a registered doctor
• The care of your patient is your irst concern
• Protect and promote the health of patients and the public
• Provide a good standard of practice and care
• Keep your professional knowledge and skills up to date
• Recognise and work within the limits of your competence

• Work with colleagues to serve your patients’ interests best
• Treat patients as individuals and respect their dignity
• Treat patients politely and considerately
• Respect patient conidentiality
• Work in partnership with the patient
• Listen to your patients and respond to their concerns and
preferences
• Give information in a way they can understand
• Respect their right to reach decisions with you about
their care
• Support patients in caring for themselves to improve and
maintain their health
• Be honest and open, and act with integrity
• Act without delay if you have a good reason to believe that
you or a colleague may be putting patients at risk
• Never discriminate unfairly against patients or colleagues
• Never abuse your patient’s or the public’s trust in you or
the profession
Courtesy of the General Medical Council (UK).

their families. This information is conidential, even after
a patient’s death. This is a general rule, although its legal
application varies between countries. In the UK, follow
the guidelines issued by the General Medical Council
(Box 1.1). There are exceptions to the general rules governing patient conidentiality, where failure to disclose
information would put the patient or someone else at
risk of death or serious harm, or where disclosure might
assist in the prevention, detection or prosecution of a
serious crime. If you ind yourself in this situation,
contact the senior doctor in charge of the patient’s care

immediately and inform him or her of the situation.
Take all reasonable steps to ensure that consultation
and examination of a patient is private. Never discuss
patients where you can be overheard or leave patients’
records, either on paper or on screen, where they can be
seen by other patients, unauthorised staff or the public.
Always obtain consent or other valid authority before
undertaking any examination or investigation, providing treatment or involving patients in teaching or
research. Even where you have been given signed
consent to disclose information about the patient, only
disclose what is being asked for. If you have any doubts
discuss your report with the patient so that he is clear
about what information is going to a third party.
Clearly record your indings in the patient’s case
notes immediately after the consultation. These case
notes are conidential and must be stored securely.
They also constitute a legal document that could be
used in a court of law. Keeping accurate and up-to-date
case notes is an essential part of good patient care
(p. 38). Remember that what you write may be seen by
the patient, as in many countries, including the UK,
patients can ask for and receive access to their medical
records.


Hand washing and cleanliness

PERSONAL RESPONSIBILITIES
Always look after yourself and maintain your own
health. Register with a general practitioner (GP). Do not

self-diagnose and self-treat. If you know, or think that
you might have, a serious condition you could pass
on to patients, or if your judgement or performance
could be affected by a condition or its treatment, consult
your GP and be guided as to the need for secondary
referral. Heed your doctor’s advice regarding investigations, treatment and changes to your working practice.
Protect yourself, your patients and your colleagues
by being immunised against common but serious communicable diseases where vaccines are available, e.g.
hepatitis B.
Your professional position is a privileged one; do not
use it to establish or pursue a sexual or improper emotional relationship with a patient or someone close to the
patient. Do not give medical care to anyone with whom
you have a close personal relationship. Do not express
your personal beliefs, including political, religious or
moral ones, to your patients in ways that exploit their
vulnerability or could cause them distress.

DRESS AND DEMEANOUR
The way you dress is important in establishing a successful patient–doctor relationship. Your dress style and
demeanour should never make your patient or colleagues uncomfortable or distract them. Smart, sensitive
and modest dress is appropriate; expressing your personality is not. Exposing your chest, midriff and legs
may not only create offence but impede communication.
Have short or three-quarter-length sleeves or roll long
sleeves up, away from your wrists, before examining
patients or carrying out procedures. This allows you to
clean your hands effectively and reduces the risk of
cross-infection. Tie back long hair and keep any jewellery simple and limited to allow effective hand washing.
Some medical schools and hospitals require students
and staff to wear white coats or ‘scrubs’ for reasons of
professionalism, identiication and as a barrier to infection. If this is the case, these must be clean and smart

and you should always wear a name badge which can
be read easily, i.e. not at your waist.
Whenever you see a patient or relative, introduce
yourself fully and clearly. A friendly smile helps to put
your patient at ease.
How you speak to, and address, a patient depends
upon the patient’s age, background and cultural environment. Many older patients prefer not to be called by
their irst name, and it is best to ask patients how they
would prefer to be addressed.

vulnerability and clinician burnout. Improve your skills
by videoing yourself consulting with a patient (having
obtained informed signed consent) and review this with
a senior clinician using one of the many techniques
developed for this. Continually seek to improve your
communication skills. These will develop with experience but can always be improved.
Most doctors and nurses work in teams with colleagues in other professions. Working in teams does not
change your personal accountability for your conduct
and the care you provide. Try to act as a positive role
model and motivate and inspire your colleagues. Always
respect the skills and contributions of your colleagues
and communicate effectively with them particularly
when handing over care.

1

EXPECTATIONS AND RESPECT
The literary and media stereotypes of doctors frequently
involve miraculous intuition, the conirmation of rare
and brilliant diagnoses and the performance of dramatic

life-saving interventions. Reality is different. Medicine
often involves seeing and treating patients with common
conditions and chronic diseases where we may only be
able to provide palliation or simply bear witness to
patients’ suffering. The best doctors are humble and
recognise that humans are ininitely more complex,
demanding and fascinating than one can imagine. They
understand that much so-called medical ‘wisdom’ is at
best incomplete, and often simply wrong.
If a patient under your care has suffered harm or
distress, act immediately to put matters right, if that is
possible. Apologise and explain fully and promptly to
the patient what has happened, and the likely effects.
Patient complaints about their care or treatment are
often the result of a breakdown in communication and
they have a right to expect a prompt, open, constructive
and honest response. Do not allow a patient’s complaint
to affect adversely the care or treatment you provide.

HAND WASHING AND CLEANLINESS
Transmission of microorganisms from the hands of
healthcare workers is the main source of cross-infection

1.2 Infections that can be transmitted on
the hands of healthcare workers
Healthcare-acquired infections

• Meticillin-resistant Staphylococcus
aureus (MRSA)

• Clostridium difficile

Diarrhoeal infections

COMMUNICATION SKILLS
A consultation is a meeting of two experts: you as the
clinician and the patient as an expert on his own body
and mind. Excellent communication skills allow you to
identify a patient’s problem rapidly and accurately
and improve patient satisfaction (p. 7). Poor communication skills are associated with increased medicolegal

• Salmonella
• Escherichia coli 0157:H7

• Shigella
• Norovirus

Respiratory infections

• Inluenza
• Respiratory syncytial virus (RSV)

• Common cold

Other infections

• Hepatitis A
3

APPROACH TO THE PATIENT

1

How to hand rub
with alcohol based hand rub
1

How to handwash
with soap and water
1

Wet hands and apply enough
soap to cover all hand surfaces

Apply a palmful of the product
and cover all hand surfaces

2

3

4

8
Rub hands palm to palm

Right palm over the back of the
other hand with interlaced
fingers and vice versa

5

6

Palm to palm with
fingers interlaced
7
Rinse hands with water
9

Backs of fingers to opposing
palms with fingers interlocked

8

Steps 2–7 should take
at least 15 seconds

Rotational rubbing of left
thumb clasped in right
palm and vice versa

11

Rotational rubbing, backwards
and forwards with clasped
fingers of right hand in left
palm and vice versa

Steps 2–7 should take
at least 15 seconds

Dry thoroughly with towel
10

Use elbow to turn off tap

Fig. 1.1 How do I clean my hands properly? © World Health Organization 2009. All rights reserved.

in hospitals, primary care surgeries and nursing homes.
Healthcare-acquired infections complicate up to 10% of
hospital admissions and in the UK 5000 people die from
them each year (Box 1.2).
Hand washing is the single most effective way to
prevent the spread of infection. It is your responsibility
to prevent the spread of infection and routinely wash
your hands after every clinical examination. Do not be
put off by lack of hand hygiene agents or facilities for
hand washing, or being short of time.
• If your hands are visibly soiled, wash thoroughly
with soap and water.

4

• If your hands are not obviously dirty, wash with
soap and water or use an alcohol-based rub
or gel.
• Always wear surgical gloves when you may be in
contact with blood, mucous membranes or nonintact skin.

While washing with alcohol-based gels will remove
most microorganisms, e.g. meticillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, Salmonella), when
dealing with patients with inluenza, norovirus or
Clostridium difficile infection, always clean hands with
liquid soap and water (Fig. 1.1).


SECTION 1 HISTORY TAKING AND GENERAL EXAMINATION
David Snadden
Robert Laing
Stephen Potts
Fiona Nicol
Nicki Colledge

History taking

TALKING WITH PATIENTS 6
Patient-centred medicine 6
Beginning 6
Dificult situations 9
Your patient has communication
dificulties 9
Your patient has cognitive dificulties 9
Sensitive situations 9
Gathering information 11
THE PSYCHIATRIC HISTORY 21

The history 21
Sensitive topics 21
The uncooperative patient 21

Mental state examination 21
Appearance 22
Behaviour 22
Speech 22
Mood 22
Thought form 22
Thought content 23
Risk assessment 25
Screening questions for mental illnesses 25

2
The physical examination 26
MEDICALLY UNEXPLAINED SYMPTOMS
(MUS) 27
Symptoms and deinitions 27
History 28
Physical examination 29
Investigation 29
Putting it all together 29
DOCUMENTING THE FINDINGS:
THE CASE NOTES 30

5


HISTORY TAKING

2

TALKING WITH PATIENTS

Think about the last time you visited your doctor. What
prompted your visit? What arrangements did you have
to make? Even a straightforward visit can be a big event.
You have to make an appointment, work out what you
are going to say and possibly arrange time off work or
for child care. People visit doctors for many reasons (Box
2.1). They may have already spoken to family, friends or
other health professionals, tried various remedies, and
trawled the internet for information to explain their
illness or problem. Most patients have some idea of what
might be wrong with them and have worries or concerns
they wish to discuss.
All patients seek explanation and meaning for their
symptoms. You need to work out why the patient has
come to see you, what he is most concerned about, and
then agree with him the best course of action.
The irst and major part of any consultation is talking
with your patient. Communication is integral to clinical
examination and is most important both at the start of
the interview, to gather information, and at the end, to
ind common ground and engage your patient in his
management.

your patients in their healthcare. Poor communication
leads to misunderstanding, conlicting messages and
patient dissatisfaction, and is the root cause of complaints and litigation. Over time you will develop your
own consulting style; consultation frameworks are
useful places to start (Box 2.4).

BEGINNING

Setting up
Preparation
Read your patient’s records and any transfer or admission letters before you see your patient.

Where will you see your patient?
Choose a quiet, private space. This is often dificult in
hospital, where privacy may be afforded only by curtains, which means no privacy at all. Always be sensitive

PATIENT-CENTRED MEDICINE
Patient-centred medicine helps you understand your
patient as a whole person. Good communication supports the building of trust between you and your patient
and helps you provide clear and simple information
(Boxes 2.2 and 2.3). It allows you to understand each
other and agree goals together. Communication means
much more than ‘taking a history’; it is about involving

2.3 Tips for effective conversations
•
•
•
•
•
•
•
•
•

2.1 Reasons why people visit doctors
•
•

•
•
•

They have reached their limits of tolerance
They have reached their limits of anxiety
They have problems of daily living presenting as symptoms
For prevention
For administrative reasons

•
•
•

Speak clearly and audibly
Ask open questions to start with
Don’t interrupt your patient
Try and appear unhurried
Use silence to encourage explanations
Do not use jargon or emotive words
Find out about your patient as a person
Clarify and summarise what you understand – you may need
to do this more than once
Make sure the story makes sense to you – keep seeking
facts until it does
Acknowledge emotions
Seek ideas, concerns and expectations
Negotiate mutual goals

2.4 Consulting with patients (BASICS)

Beginning

2.2 Effective communication skills
Improve patient satisfaction

Active listening

• Patients understand what is wrong
• They understand what they can do to help

• The patient’s experience of his illness

Improve doctor satisfaction

• Patients are more likely to follow advice when they agree
mutual goals with their doctor

6

• Setting up
• Preparation
• Introduction

Systematic enquiry

• Disease-oriented systematic enquiry
Information gathering

Improve health by positive support and empathy

• Clinical examination

• Improve health outcomes
• Enhance the relationship between doctor and patient

Context

Use time more effectively

Sharing

• Active listening helps the doctor recognise what is wrong
• Active listening leads to fewer patient complaints

• Information
• Agreeing action and goals

• Understanding your patient as a person