Mark Dennis, William Talbot Bowen, Lucy Cho
Churchill Livingstone Elsevier 2012
Paperback 515 pages RRP $75.00
A Student Consult title - full text searchable online (after registration).
Further information (including a sample chapter) available at: http://www.elsevierhealth.com.au/au/product.jsp?sid=&isbn=9780729540759&lid=EHS_ANZ_BS-DIS-1&iid
Thanks are due to Elsevier Australia for kindly providing a review copy of this book. The authors have crafted a gem of a book, which would not be out of place in any medical library, regardless of the seniority of the practitioner. It is all the more remarkable for being put together by three Resident Medical Officers (two Australians and an American), and this international approach serves to increase its utility.
Each chapter was reviewed by experts in the relevant discipline, and the authors explain the provenance of their research in a caveat concerning the rate of change of medical knowledge and the possibility of obsolesence of their work: "... the authors used reference texts as well as Medline, PubMed, Embase, SCIRUS and other databases - firstly to identify all relevant signs and secondly to find the most up-to-date information about them. Every attempt has been made to provide the reader with the most recent information, however ...".
The book opens with two separate Contents listings. The first is divided up by 'Signs' - Musculoskeletal, Respiratory, Cardiovascular, Haematological/Oncological, Neurological and Endocrinological. The second lists Contents by Condition. There is also a detailed Index at the back of the book. By working between these three resources, it is fairly easy to find what you are looking for. the actual layout of the book is in seven chapters, as per the categorisation of the 'Signs' above. Each chapter is followed by a list of references, and there is also a listing of picture credits preceding the Index at the back. A list of abbreviations is also provided prior to Chapter 1.
The degree of coverage of each sign is quite variable. Some are covered very briefly in just a couple of paragraphs, while others ('dyspnoea' for example) are given 2-3 pages, and figures, tables and flow-chart mechanisms sometimes provided. There is a consistent internal layout, in general consisting of 'Description', 'Condition/s associated with ...', 'Mechanism/s' and 'Sign Value'.
The emphasis of the book is very much on general (or 'internal') medicine, and as such does not offer an equal level of coverage for either paediatrics or obstetric medicine, but some signs are acknowledged as occurring in pregnancy and a brief discussion provided.
Taking COPD (chronic obstructive pulmonary disease) as an example, it is important to realise that this condition is a constellation of signs and symptoms, and this book is not designed to provide an overall pathophysiological mechanism (this is the province of other references on the market). Thus COPD is not listed as a respiratory 'sign', but in the 'Contents by Condition' index, there is fairly comprehensive coverage of many common signs which are associated with COPD. These are: dyspnoea, Harrison's sign, tachypnoea, pursed lips breathing, barrel chest, crackles, wheeze, hyperventilation, clubbing, intercostal recession, paradoxical respiration, hyper-resonance to percussion, vocal fremitus and vocal resonance.
It is probably useful to illustrate the contents by randomly choosing three signs to examine. The first one selected is 'clubbing'. Most medical students will tell you that the mechanism is not clearly understood, and the text acknowledges this. This section is clearly written, well set-out and useful. It commences with a picture of clubbing of the fingers and toes followed by a multi-point description, a listing of conditions commonly associated with clubbing, a survey of the current thinking regarding the underlying mechanism, a short flow chart ('mechanism') reflecting this thinking, a succinct summary concerning the 'sign value' and a table setting out the causes of bilateral clubbing by body system.
The second example is a 'relative afferent pupillary defect' (Marcus Gunn pupil). The chapter on neurological signs contains some extra material designed to assist the reader in the form of coloured boxes entitled "Relevant neuroanatomy and topographical anatomy", which demonstrate the relevant anatomical pathways. It would be fair to say that understanding this sign is commonly found to be challenging. An anatomical pathway is provided for both the afferent and efferent limb (but this does not go into detail as to whether parasympathetic or sympathetic fibres are involved) as well as a helpful diagram illustrating the appearance of the pupils with the 'swinging torch test'. The second page contains a further diagrammatical representation of the anatomical structures and pathways. The text sets out common and less common conditions associated with a RAPD, and then provides a short discussion of the mechanism and optic nerve disorders and retinal neuroepithelium disorders (rare), concluding with the 'sign value'. Having researched this topic when teaching it to students several months ago, I would reflectively say that this exposition, whilst clear and helpful to the novice, does not present the level of detail that I was looking for at the time. However, for a simple and superficial explanation it is more than adequate.
The third topic selected is haematemesis. I also recently researched this topic whilst reviewing a proposed clinical exam paper. This is covered in the gastrointestinal chapter as "Coffee ground vomiting/bloody vomitus/haematemesis". One and a bit pages are devoted to the topic. The text contains a description together with a list of more common and less common conditions associated with upper gastrointestinal bleeding. These listings are quite helpful, but as some examples of 'nitpicking', the generic term 'peptic ulcer disease' is used without explanation (and the 'upper GIT' is not defined either). Having been involved in teaching, I have come to appreciate that there are many commonly used terms that have a 'rubbery' understanding of what they actually mean, and that there is value in clarification in such cases. Where this section shines is in the explanation of the General Mechanism/s and specific explanations for peptic ulcer disease, Mallory-Weiss tears and oesophageal varices (including their relationship to portal hypertension). There are also simple mechanisms provided for a Mallory-Weiss tear and bleeding from oesophageal varices. The section concludes with the 'Sign Value', which provides helpful and pragmatic advice.
A book like this cannot be all things to all people. Some topics will provide you with a 'light-bulb moment' and others will leave you wanting more. It is however an invaluable resource, not only for the practitioner in terms of individual understanding of clinical signs, but also in providing clear, simple and comprehensible explanations that can form the basis of an authoritative explanation to patients and their carers. I can also see that it would have enormous utility in General Practice, where patients will randomly present with unfamiliar signs (particularly if you are a Registrar). It is the kind of book that we all really should read from cover to cover, "if only I had the time ..."!
Highly recommended. A good investment which will more than repay its purchase price over time.
