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Sorting through the signs
DISSECTING ROOM
and misleading text. It should be possible to magnify the windows, or at least illuminate the background. The layout is adequate for such welldefined things as muscle origins on bare bones, but add layers, and the detail becomes distinctly murky. On most still screens, there are blue and green squares in the right hand corner that are joined by an arrow, which means MRI can be used to match the diagram, or vice-versa. The MRI forward button will make the diagram track, but the contrary is not true. The “layer scroller” on the model of the sagittal ankle just takes away slices, not layers. On the lumbar spine screen, there are kidneys on the MRI image, but because you are not able to obtain a superficial view on the coronal sections, you do not end up with the corresponding MRI slice. On the spine disc, autorotate only means swivel, although if you then look at the coronal and sagittal models you do get the whole picture, albeit in pieces. There are useful multiple choice tests in each section, but these are marred by indistinct red cross-hatches that are
meant to highlight the relevant piece of anatomy. No-one apparently reviewed or cross-read the clinical and radiology text, which is repeated at embarrassing length, especially in the description of the Achilles’ tendon. This oversimplified section is full of typographical errors and strange formatting. The section on clinical pathology is even weaker, and illustrated by unclear MRI slides. Multiple clicks are needed to see these slides properly, and you never know whether you are going to see the live male body, or a blue glove plucking at tendons in a darkened room, which is a little disconcerting. If you are curious about the “concept of ulnar variance”, click on the link, and a power point slide crops up with two bullet points. The text is more useful when it simply describes what is shown. I could not see the point of describing ossification centres, if they are not illustrated—an embryogenesis CD-ROM is needed to do that subject justice. An unsuccessful attempt has been made to join line
drawings to cadavers by red text that links to dissection photographs of the region in question; structures cannot be selected by the mouse with the same accuracy. On the knee CD-ROM there are great film sequences of the anterior and posterior cruciate ligaments in flexion, and watching these ligaments slide across the idealised surface of a medial condylar notch makes one wince for all the arthritic catches that age puts there in time. A sequence showing the screw home motion of the patellar during knee flexion is a masterpiece of simplicity and probably the most useful tool for patients’ education in this set. These CD-ROMs essentially replace, at considerable expense, the acetate sheets that used to make up multilayered anatomical illustrations. The designers might want to give some thought to the nostalgia they thereby induce for a big heavy book with real pages and accurate content. Laragh Gollogly The Lancet, London, UK
Sorting through the signs Evidence-Based Physical Diagnosis Steven McGee. Philadelphia: W B Saunders, 2001. Pp 910. $45.95. ISBN 0721686931.
E
vidence-Based Physical Diagnosis attempts to integrate the tradition and history of physical examination with the growing body of evidence about the diagnostic accuracy and reliability of the various physical findings that physicians use to assess patients. Steven McGee, an associate professor of internal medicine with some 20 years’ experience of teaching physical examination skills to medical students, has done an excellent job of integrating these disparate subjects. The first three chapters are devoted to a detailed discussion of probabilities, diagnostic accuracy, and reliability. These initial chapters are beautifully written, and include one of the most readable accounts of likelihood ratios I have encountered. Clinicians, who need simple and practical tools, will appreciate the methods for approximating post-test probability that are outlined in this section. After this introductory section, there are 56 chapters about the physical findings in a particular disease state, for example, in patients with pulmonary embolism or anaemia. Most chapters include tables that list sensitivities, specificities, and likelihood ratios for
each sign and these data are the highlights of the text. For example, table 36.1 shows these features for the third and fourth heart sounds. The tables are kept simple by including only a single number or a range for each value, but a concluding chapter lists confidence intervals for each of the likelihood ratios cited in the text. Similarly, the presentation of the Wells scoring scheme for pretest probability of deep-vein thrombosis (tables 50.2, 50.3) was comprehensive and its role in clinical practice well defined. The organisation of the text can be challenging. McGee has placed the chapter on mental status in the section on general appearance; similarly, the chapters on hearing and pupils are in the head and neck section, rather than in the section on neurological examination. The amount of detail for topics varies widely. There is an in-depth and useful discussion of pupillary reflexes, which explores both the history and the diagnostic algorithm for abnormal findings. By contrast, the sections on protein-energy malnutrition, weight loss, and hypovolaemia are superficial. Some important topics,
THE LANCET • Vol 359 • April 6, 2002 • www.thelancet.com
such as examination of the breast, male genitals, and pelvic area are not addressed at all. Furthermore, some disease states are explored in detail, whereas others receive only cursory treatment—for example, the five indepth cardiology topics are not balanced by any detailed explorations of the abdominal examination. However, this shortcoming may reflect the limited data on certain topics. The detailed chapter on congestive heart failure is excellent, but it would have been useful to have a similar discussion of the findings of physical examination in coronary artery disease (Levine’s sign, earlobe creases, or xanthelasma). This book, with its inclusion in one place of so much data on the reliability of physical findings is a welcome adjunct to the teaching of physical diagnosis to medical students. Evidence-Based Physical Diagnosis would also assist the more experienced clinician in honing their understanding of the usefulness of physical diagnosis findings and manoeuvres. McGee does presuppose a substantial baseline knowledge in the reader and omits discussion of several important body systems, so the book is not for inexperienced practitioners. *Lorne Becker, Sara Jo Grethlein Department of Family Medicine, SUNY Health Science Center at Syracuse, Syracuse, NY 13210, USA
1257
For personal use. Only reproduce with permission from The Lancet Publishing Group.
and misleading text. It should be possible to magnify the windows, or at least illuminate the background. The layout is adequate for such welldefined things as muscle origins on bare bones, but add layers, and the detail becomes distinctly murky. On most still screens, there are blue and green squares in the right hand corner that are joined by an arrow, which means MRI can be used to match the diagram, or vice-versa. The MRI forward button will make the diagram track, but the contrary is not true. The “layer scroller” on the model of the sagittal ankle just takes away slices, not layers. On the lumbar spine screen, there are kidneys on the MRI image, but because you are not able to obtain a superficial view on the coronal sections, you do not end up with the corresponding MRI slice. On the spine disc, autorotate only means swivel, although if you then look at the coronal and sagittal models you do get the whole picture, albeit in pieces. There are useful multiple choice tests in each section, but these are marred by indistinct red cross-hatches that are
meant to highlight the relevant piece of anatomy. No-one apparently reviewed or cross-read the clinical and radiology text, which is repeated at embarrassing length, especially in the description of the Achilles’ tendon. This oversimplified section is full of typographical errors and strange formatting. The section on clinical pathology is even weaker, and illustrated by unclear MRI slides. Multiple clicks are needed to see these slides properly, and you never know whether you are going to see the live male body, or a blue glove plucking at tendons in a darkened room, which is a little disconcerting. If you are curious about the “concept of ulnar variance”, click on the link, and a power point slide crops up with two bullet points. The text is more useful when it simply describes what is shown. I could not see the point of describing ossification centres, if they are not illustrated—an embryogenesis CD-ROM is needed to do that subject justice. An unsuccessful attempt has been made to join line
drawings to cadavers by red text that links to dissection photographs of the region in question; structures cannot be selected by the mouse with the same accuracy. On the knee CD-ROM there are great film sequences of the anterior and posterior cruciate ligaments in flexion, and watching these ligaments slide across the idealised surface of a medial condylar notch makes one wince for all the arthritic catches that age puts there in time. A sequence showing the screw home motion of the patellar during knee flexion is a masterpiece of simplicity and probably the most useful tool for patients’ education in this set. These CD-ROMs essentially replace, at considerable expense, the acetate sheets that used to make up multilayered anatomical illustrations. The designers might want to give some thought to the nostalgia they thereby induce for a big heavy book with real pages and accurate content. Laragh Gollogly The Lancet, London, UK
Sorting through the signs Evidence-Based Physical Diagnosis Steven McGee. Philadelphia: W B Saunders, 2001. Pp 910. $45.95. ISBN 0721686931.
E
vidence-Based Physical Diagnosis attempts to integrate the tradition and history of physical examination with the growing body of evidence about the diagnostic accuracy and reliability of the various physical findings that physicians use to assess patients. Steven McGee, an associate professor of internal medicine with some 20 years’ experience of teaching physical examination skills to medical students, has done an excellent job of integrating these disparate subjects. The first three chapters are devoted to a detailed discussion of probabilities, diagnostic accuracy, and reliability. These initial chapters are beautifully written, and include one of the most readable accounts of likelihood ratios I have encountered. Clinicians, who need simple and practical tools, will appreciate the methods for approximating post-test probability that are outlined in this section. After this introductory section, there are 56 chapters about the physical findings in a particular disease state, for example, in patients with pulmonary embolism or anaemia. Most chapters include tables that list sensitivities, specificities, and likelihood ratios for
each sign and these data are the highlights of the text. For example, table 36.1 shows these features for the third and fourth heart sounds. The tables are kept simple by including only a single number or a range for each value, but a concluding chapter lists confidence intervals for each of the likelihood ratios cited in the text. Similarly, the presentation of the Wells scoring scheme for pretest probability of deep-vein thrombosis (tables 50.2, 50.3) was comprehensive and its role in clinical practice well defined. The organisation of the text can be challenging. McGee has placed the chapter on mental status in the section on general appearance; similarly, the chapters on hearing and pupils are in the head and neck section, rather than in the section on neurological examination. The amount of detail for topics varies widely. There is an in-depth and useful discussion of pupillary reflexes, which explores both the history and the diagnostic algorithm for abnormal findings. By contrast, the sections on protein-energy malnutrition, weight loss, and hypovolaemia are superficial. Some important topics,
THE LANCET • Vol 359 • April 6, 2002 • www.thelancet.com
such as examination of the breast, male genitals, and pelvic area are not addressed at all. Furthermore, some disease states are explored in detail, whereas others receive only cursory treatment—for example, the five indepth cardiology topics are not balanced by any detailed explorations of the abdominal examination. However, this shortcoming may reflect the limited data on certain topics. The detailed chapter on congestive heart failure is excellent, but it would have been useful to have a similar discussion of the findings of physical examination in coronary artery disease (Levine’s sign, earlobe creases, or xanthelasma). This book, with its inclusion in one place of so much data on the reliability of physical findings is a welcome adjunct to the teaching of physical diagnosis to medical students. Evidence-Based Physical Diagnosis would also assist the more experienced clinician in honing their understanding of the usefulness of physical diagnosis findings and manoeuvres. McGee does presuppose a substantial baseline knowledge in the reader and omits discussion of several important body systems, so the book is not for inexperienced practitioners. *Lorne Becker, Sara Jo Grethlein Department of Family Medicine, SUNY Health Science Center at Syracuse, Syracuse, NY 13210, USA
1257
For personal use. Only reproduce with permission from The Lancet Publishing Group.