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Recognizing Clinical Patterns: Clues to a Timely Diagnosis
Book Reviews
Review by Jeffrey S. Engel, DO, and Louis Binder, MD
Recognizing Clinical Patterns: Clues to a Timely Diagnosis
Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice
Mark A. Marinella, MD Hanley & Belfus, 2001 246 pages, $35 ISBN 1-56053-485-0
Recognizing Clinical Patterns: Clues to a Timely Diagnosis
Review by Bennett Shamsai, MD, MPH
Copyright © 2002 by the American College of Emergency Physicians. 0196-0644/2002/$35.00 + 0 47/8/125447 doi:10.1067/mem.2002.125447
JULY 2002
40:1
The premise of the book is to enhance “pattern recognition” of “classic” presentations of disease in clinical medicine: typical symptoms, signs, and selected supplemental data (eg, laboratory, radiograph, ECG) that should trigger a clinician to consider a specific diagnosis. Rapid clinical pattern recognition is a key part of what we do at the bedside in emergency medicine; it differentiates the ability of the experienced and effective clinician from physicians with limited experience in general clinical medicine. It also allows us to make rapid and accurate diagnostic assessments and to move quickly from case to case. This book is organized into the following categories: cardiovascular, rheumatologic, pulmonary, gastrointestinal/hepatobiliary, endocrine/ metabolic/nutritional, renal, oncologic, hematologic, infectious, neurologic, toxic/environmental, and miscellaneous disorders. Twelve disease categories and 159 cases comprise the contents of the book. One of the most interesting parts of this book was the toxic/environmental chapter.
ANNALS OF EMERGENCY MEDICINE
Among the subjects reviewed are the more common vignettes, such as heroin overdose, INH, and salicylate toxicity, and carbon monoxide poisoning; in addition, other interesting and rare disorders are reviewed, such as lactrodectism, scombroid and ciguatera fish poisoning, and Amanita phalloides ingestion. Each chapter focuses on a particular set of common and uncommon disease processes affecting that particular system. With each case, a brief patient description depicting a presenting pattern of disease is represented in boldfaced type at the top of the page. The diagnosis and some basic information about the disease follow. Next, common and rare presentation patterns are reviewed, as are the pertinent positives and negatives of the physical examination. Various diagnostic tests needed and the common results of these tests are then reviewed. Commonly, at the end of the vignettes, an illustration is presented. Each presentation is covered in 1 to 2 pages, giving the quick and concise review of disease necessary for a board review text, although not the more detailed explanations encountered in an emergency medicine review text. The target for this book is the general clinician (eg, emergency physician, family physician, internist, allied health care provider) who, by the nature of his or her practice, will see broad-based symptomatic presenta1 3 1
BOOK REVIEWS
tion patterns. This book is authored by an internist, but many of the diseases covered are also seen fairly commonly in the emergency department. Because of the general way in which this publication covers disease presentations and because it reads quickly, I would recommend this book to any clinician, resident, or medical student in need of a vignette format as they prepare for any board examination; it would also be a welcome addition to a teaching library. However, because of its lack of detail of most processes, I would not recommend this book as an ED reference text. Jeffrey S. Engel, DO Emergency Medicine Residency Case Western Reserve University/ MetroHealth Medical Center/Cleveland Clinic Foundation Cleveland, OH Louis Binder, MD Department of Emergency Medicine MetroHealth Medical Center Cleveland, OH
Users’ Guides to the Medical Literature: A Manual for EvidenceBased Clinical Practice Guyatt G, Rennie D (eds) American Medical Association Press, 2001 706 pages, $59.95 (Book With CD-ROM) ISBN 1-57947-174-9
The Users’ Guides to the Medical Literature is a comprehensive guide on how to find, understand, use, and judge medical literature. It is an edited collection of 25 works published in The Journal of the American Medical Association from 1993 to 2000 that is “designed to make the clinician fluent in the language of the medical literature in all its forms.” Does it achieve this goal? It comes commendably close. This text does not teach how to design a study but rather how to judge one done by others—explaining the 1 3 2
subtleties of bias, the role of statistics, and the special challenges to conducting medical research. It is divided into 2 major sections. Part 1 is intended as the “quick and dirty” knowledge that every clinician in today’s world should know, and Part 2 discusses the same topics in greater depth, intended for those who may teach evidence-based medicine (EBM) or who may require or desire more depth. Topics are ordered in such a way that Part 1 (“the basics”) mirrors Part 2 (“the greater depth”), thereby allowing the reader to move between the 2 parts of the book seamlessly. This effectively allows the reader 2 fundamental ways to read this book: straight through or alternating between the 2 parts as needed. (The book also comes with a hypertext CD-ROM version that makes transitioning between Part 1 and Part 2 even easier.) The Users’ Guides to the Medical Literature starts off by explaining the fundamentals of EBM. Each chapter looks at a specific type of question and discusses the best method to answer it. Using case examples, the authors walk you through the process of taking a clinical question, searching the literature (emphasizing Internet resources), analyzing the results, and applying this to the patient at hand. In addition, the authors simultaneously teach a new aspect of EBM, with each progressing chapter adding another layer of understanding of the complexities of evidence-based medicine. It dissects the many subtle faces of bias, from patient selection to the importance of follow-up. This knowledge is intermingled with a social message about the role of a physician, which, although intellectually interesting, can be distracting from the primary goal of the book. The number of authors leads to many redundancies throughout and to large variations in writing style. Some topics that would be considered fundamental, such as type I ver-
sus type II error, were not covered until late in Part 2 of the book. I believe that adding a chapter on basic statistics in the beginning of the text would have served as a good foundation for the rest of the book. In the authors’ defense, there is a nice appendix with many of the statistical formulas in it, as well as a superb glossary of many of the terms heard when discussing EBM. The breadth of material this book tries to cover is immense, and the authors do a commendable and comprehensive job of presenting the material, making this book an incredible resource for anyone serious about EBM. If you are designing an EBM curriculum at your medical school, this book should be in your arsenal along with a text of statistics. If, on the other hand, you are a practitioner with a desire to get a handle on EBM, this text is overly comprehensive (even just Part 1) and is certainly not “light” reading. For most practicing emergency physicians, reading it from cover to cover would be daunting because of the time commitment involved in reading its 600-plus pages, but it will leave you with a greatly expanded ability to find, analyze, and apply medical literature to your practice. (There is a pocket-sized version of this text, Users’ Guides to the Medical Literature: Essentials of Evidence-Based Clinical Practice, that is much less lengthy and thus easier to read while still providing a good understanding of EBM [2001, 442 pages, $34.95, ISBN 1-57947-191-9].) This book offers a tremendous amount of useful information and appears to be the best collection to date of how to practice EBM. For a general clinician, it could be used as a valuable reference, whereas for the teacher of EBM, it could be used as a foundation for a full course and is a “must read” book. Bennett T. Shamsai, MD, MPH Department of Emergency Medicine Thomas Jefferson University Philadelphia, PA
ANNALS OF EMERGENCY MEDICINE
40:1
JULY 2002
Review by Jeffrey S. Engel, DO, and Louis Binder, MD
Recognizing Clinical Patterns: Clues to a Timely Diagnosis
Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice
Mark A. Marinella, MD Hanley & Belfus, 2001 246 pages, $35 ISBN 1-56053-485-0
Recognizing Clinical Patterns: Clues to a Timely Diagnosis
Review by Bennett Shamsai, MD, MPH
Copyright © 2002 by the American College of Emergency Physicians. 0196-0644/2002/$35.00 + 0 47/8/125447 doi:10.1067/mem.2002.125447
JULY 2002
40:1
The premise of the book is to enhance “pattern recognition” of “classic” presentations of disease in clinical medicine: typical symptoms, signs, and selected supplemental data (eg, laboratory, radiograph, ECG) that should trigger a clinician to consider a specific diagnosis. Rapid clinical pattern recognition is a key part of what we do at the bedside in emergency medicine; it differentiates the ability of the experienced and effective clinician from physicians with limited experience in general clinical medicine. It also allows us to make rapid and accurate diagnostic assessments and to move quickly from case to case. This book is organized into the following categories: cardiovascular, rheumatologic, pulmonary, gastrointestinal/hepatobiliary, endocrine/ metabolic/nutritional, renal, oncologic, hematologic, infectious, neurologic, toxic/environmental, and miscellaneous disorders. Twelve disease categories and 159 cases comprise the contents of the book. One of the most interesting parts of this book was the toxic/environmental chapter.
ANNALS OF EMERGENCY MEDICINE
Among the subjects reviewed are the more common vignettes, such as heroin overdose, INH, and salicylate toxicity, and carbon monoxide poisoning; in addition, other interesting and rare disorders are reviewed, such as lactrodectism, scombroid and ciguatera fish poisoning, and Amanita phalloides ingestion. Each chapter focuses on a particular set of common and uncommon disease processes affecting that particular system. With each case, a brief patient description depicting a presenting pattern of disease is represented in boldfaced type at the top of the page. The diagnosis and some basic information about the disease follow. Next, common and rare presentation patterns are reviewed, as are the pertinent positives and negatives of the physical examination. Various diagnostic tests needed and the common results of these tests are then reviewed. Commonly, at the end of the vignettes, an illustration is presented. Each presentation is covered in 1 to 2 pages, giving the quick and concise review of disease necessary for a board review text, although not the more detailed explanations encountered in an emergency medicine review text. The target for this book is the general clinician (eg, emergency physician, family physician, internist, allied health care provider) who, by the nature of his or her practice, will see broad-based symptomatic presenta1 3 1
BOOK REVIEWS
tion patterns. This book is authored by an internist, but many of the diseases covered are also seen fairly commonly in the emergency department. Because of the general way in which this publication covers disease presentations and because it reads quickly, I would recommend this book to any clinician, resident, or medical student in need of a vignette format as they prepare for any board examination; it would also be a welcome addition to a teaching library. However, because of its lack of detail of most processes, I would not recommend this book as an ED reference text. Jeffrey S. Engel, DO Emergency Medicine Residency Case Western Reserve University/ MetroHealth Medical Center/Cleveland Clinic Foundation Cleveland, OH Louis Binder, MD Department of Emergency Medicine MetroHealth Medical Center Cleveland, OH
Users’ Guides to the Medical Literature: A Manual for EvidenceBased Clinical Practice Guyatt G, Rennie D (eds) American Medical Association Press, 2001 706 pages, $59.95 (Book With CD-ROM) ISBN 1-57947-174-9
The Users’ Guides to the Medical Literature is a comprehensive guide on how to find, understand, use, and judge medical literature. It is an edited collection of 25 works published in The Journal of the American Medical Association from 1993 to 2000 that is “designed to make the clinician fluent in the language of the medical literature in all its forms.” Does it achieve this goal? It comes commendably close. This text does not teach how to design a study but rather how to judge one done by others—explaining the 1 3 2
subtleties of bias, the role of statistics, and the special challenges to conducting medical research. It is divided into 2 major sections. Part 1 is intended as the “quick and dirty” knowledge that every clinician in today’s world should know, and Part 2 discusses the same topics in greater depth, intended for those who may teach evidence-based medicine (EBM) or who may require or desire more depth. Topics are ordered in such a way that Part 1 (“the basics”) mirrors Part 2 (“the greater depth”), thereby allowing the reader to move between the 2 parts of the book seamlessly. This effectively allows the reader 2 fundamental ways to read this book: straight through or alternating between the 2 parts as needed. (The book also comes with a hypertext CD-ROM version that makes transitioning between Part 1 and Part 2 even easier.) The Users’ Guides to the Medical Literature starts off by explaining the fundamentals of EBM. Each chapter looks at a specific type of question and discusses the best method to answer it. Using case examples, the authors walk you through the process of taking a clinical question, searching the literature (emphasizing Internet resources), analyzing the results, and applying this to the patient at hand. In addition, the authors simultaneously teach a new aspect of EBM, with each progressing chapter adding another layer of understanding of the complexities of evidence-based medicine. It dissects the many subtle faces of bias, from patient selection to the importance of follow-up. This knowledge is intermingled with a social message about the role of a physician, which, although intellectually interesting, can be distracting from the primary goal of the book. The number of authors leads to many redundancies throughout and to large variations in writing style. Some topics that would be considered fundamental, such as type I ver-
sus type II error, were not covered until late in Part 2 of the book. I believe that adding a chapter on basic statistics in the beginning of the text would have served as a good foundation for the rest of the book. In the authors’ defense, there is a nice appendix with many of the statistical formulas in it, as well as a superb glossary of many of the terms heard when discussing EBM. The breadth of material this book tries to cover is immense, and the authors do a commendable and comprehensive job of presenting the material, making this book an incredible resource for anyone serious about EBM. If you are designing an EBM curriculum at your medical school, this book should be in your arsenal along with a text of statistics. If, on the other hand, you are a practitioner with a desire to get a handle on EBM, this text is overly comprehensive (even just Part 1) and is certainly not “light” reading. For most practicing emergency physicians, reading it from cover to cover would be daunting because of the time commitment involved in reading its 600-plus pages, but it will leave you with a greatly expanded ability to find, analyze, and apply medical literature to your practice. (There is a pocket-sized version of this text, Users’ Guides to the Medical Literature: Essentials of Evidence-Based Clinical Practice, that is much less lengthy and thus easier to read while still providing a good understanding of EBM [2001, 442 pages, $34.95, ISBN 1-57947-191-9].) This book offers a tremendous amount of useful information and appears to be the best collection to date of how to practice EBM. For a general clinician, it could be used as a valuable reference, whereas for the teacher of EBM, it could be used as a foundation for a full course and is a “must read” book. Bennett T. Shamsai, MD, MPH Department of Emergency Medicine Thomas Jefferson University Philadelphia, PA
ANNALS OF EMERGENCY MEDICINE
40:1
JULY 2002