Hutchison's clinical methods : an integrated approach to by Michael Glynn, (Gastroenterologist); W M Drake; Robert

By Michael Glynn, (Gastroenterologist); W M Drake; Robert Hutchison, Sir

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2 Could a common diagnosis have been missed, and therefore one or more tests should be repeated? 3 Is there a need for an ongoing search for rarer diagnoses with more detailed investigation? 29 30 2 General patient examination and differential diagnosis Summary Ultimately, the goal is for the clinician to use a combination of experience, knowledge and appreciation of the accuracy and limitations of various investigations to select those that will lead to the correct diagnosis and facilitate the best treatment with the least discomfort and anxiety to the patient.

This helps spread the breast tissue more evenly across the chest and makes palpation of any nodules easier. For ease of annotation, the breast is usually divided into four quadrants, with the upper outer quadrant extending into an axillary tail. Use the pads of your middle three fingers to palpate the breast, using rotatory movements gently to compress the tissue against the chest wall. Proceed systematically to examine all quadrants, the tail and areola. Sometimes it is useful to support the breast with the other hand in order to aid examination, especially when the breasts are large.

The affected leg is also tender and warmer than normal, with dilated superficial veins which do not collapse when the leg is elevated. Forceful dorsiflexion of the foot may cause pain in the calf (Homan’s sign). Sometimes extension of a deep vein thrombosis may extend up the thigh leading to a tender, hard, pal­ pable femoral vein. 19 Varicose veins. (From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. ) Examination of the breasts should form part of the routine clinical assessment, usually at the time of examination of the chest.

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