Preface

I've never met a medical student who lacked passion for making a diagnosis. And, among all the diagnoses a student might make, clinching the case right at the bedside is the most treasured. The same holds true not only for physicians in practice but also for all those involved in caring for patients-physician assistants, nurses, and physical therapists must each constantly assess their patient and consider what's wrong. The Rational Clinical Examination series, published in JAMA since 1992 and collected in this book, should appeal to anyone who wonders about the meaning of a patient's symptoms and signs. Many indispensable textbooks instruct learners on "how" to elicit the medical history and perform the physical examination, but we suspect that, once the "how" is learned, clinicians only infrequently return to what was one of their favored textbooks during their training years. When I ask clinicians to recall the book they used for physical diagnosis class in medical school, there is no pause before they state DeGowin and DeGowin, Bates, Mosby, Schwartz, or another of a select few. We see The Rational Clinical Examination as an essential companion to, and not a replacement for, these time-honored texts of the "complete" medical history and physical examination.

Although standard textbooks might clearly describe several maneuvers for detecting ascites, for example, we identify those findings that work best. Although textbooks typically march from "head to toe" without regard to diagnoses when describing the complete physical examination, we start with clinical diagnostic questions and provide data that identify the most relevant symptoms and signs. Unlike physical examination textbooks, we also provide data on what does not work, derived from a thorough review of the literature that backs up our recommendations.

Please recognize that we can never replace a great textbook on the complete medical history and physical examination because we will never be complete in describing the rational clinical examination. There are many diagnoses we have not yet reviewed and many more to come. After more than 15 years of producing systematic reviews in JAMA, which included the article that launched the evidence-based medicine movement,¹ it was time for us to update and combine our work in one resource for learners and clinicians to enjoy.

Accordingly, this book is evidence based. We present the original Rational Clinical Examination article, followed by an Update. For each topic, we recreated the original literature search and evaluated the new literature dating from 1 year before the publication of the original article to the time we prepared the Update. If anything, we tried to be even more restrictive in applying our quality measures for including new research in the Updates. The Updates follow a format similar to that of the original articles: they open with a clinical scenario, present the results of the literature search, and summarize new information. Sometimes we discovered that we had not reviewed the topic as thoroughly as we thought, so we also recount any improvements we made when we reanalyzed data. Simple tables display the new findings that we incorporate with the previously published data.

Because evidence-based guidelines for most diseases did not exist when we launched The Rational Clinical Examination series, we review the recommendations of the major federal agencies for each of the topics and highlight how our information supports or differs from those recommendations. Finally, we include a Make the Diagnosis section that gives a summary of the prior probability of the target disorder, the population for whom the target disorder should be considered, a table of likelihood ratio data for the best clinical findings, and a list of the accepted reference standards.

Some readers will want more data, so we provide a structured review of every article identified in our Update that met our inclusion criteria. These reviews are available online in an Evidence to Support the Update section, available at http://www.JAMAevidence.com. JAMAevidence is a Web site resource for learning, teaching, and practicing evidence-based medicine that includes the complete online content of The Rational Clinical Examination and the Users' Guides to the Medical Literature, along with other features, such as downloadable projection slides to enhance classroom or conference teaching and learning experience, an extensive evidence-based medicine glossary, functional calculators, question wizards, customizable worksheets, podcasts, and regular updates.

We hope that long-time readers of The Rational Clinical Examination series will recognize the painstaking care and preparation taken during the review of each topic. Every Update was reviewed by an author of the original article or a clinician who had no involvement with the original publication. Although this alone might seem reassuring and unlike typical medical textbooks, we went a step further.

For each topic, a slide presentation, called an Education Guide, has been prepared, primarily by Duke University Department of Medicine residents, or in a few cases by young clinical Duke University faculty members, all supervised by Sheri A. Keitz, MD, PhD. The Education Guides follow a similar format and have been "field-tested" among learners. The goal in preparing the Education Guides was to have the learners create a set of materials for their instructors that match how they, the learners, hope the topic would be taught. Just like the Updates themselves, the slides have also been reviewed. From this, we learned that trainees are among our most critical readers-they expect careful, accurate, and thoughtful presentation and exposition. The Education Guides slides are available online at http://www.JAMAevidence.com.

For current students, The Rational Clinical Examination demonstrates the correct way to learn the medical history and physical examination, giving direction in interpreting the results and answering questions that typical physical examination textbooks do not systematically address. For teachers, the Education Guides, amply supplemented with teacher's notes, allow you to teach physical diagnosis with an evidence-based approach. For established practitioners, perhaps far removed from their introductory physical examination course, we hope to challenge any cynicism that clinical examination is all "art." There is a science behind the art of clinical examination. We hope you discover that learning this science not only validates your role as a clinician and improves your skills but also is fun.