Doody's Review Service

Reviewer:	Charles Allred, MD (Smoky Hill Family Medicine Residency)

Description
This book is an excellent treatise on the use of evidence-based medicine (EBM) to quantitatively define the usefulness of a wide variety of clinical signs and physical maneuvers in helping to make an accurate diagnosis in symptomatic patients. EBM tables are used consistently to summarize the sensitivity, specificity, and likelihood ratios associated with each diagnostic sign. This book updates information from the fifth edition from 2021.

Purpose
The book's purpose is to offer the accuracy of the physical signs and maneuvers used to affirm or negate the presence of diseases in individuals. This is a vital goal as this is an area of medicine that does not receive enough attention and has not received adequate systematic study. The book achieves its aim in an exceptional fashion through an exhaustive review of the literature to determine which physical signs have evidence to support their use in the diagnostic process. The book then further quantifies the efficacy of a wide variety of clinical signs and physical examination maneuvers using likelihood ratios and pre-test probability.

Audience
This book is written for students, house officers, and clinical staff. It is detailed and dense to read; there are no extraneous words. Though there is some content about how to perform a specific physical examination maneuver, in general this is not a book about performing a physical examination. Rather, this is a book about what examinations are helpful in making a diagnosis once clinicians know how to perform the test extremely well. There are five prior editions of this book, all written by a single author who is a recognized expert in the field of physical diagnosis and the instruction of physical diagnostic skills.

Features
The first five chapters of the book are an excellent primer on evidence-based medicine, in particular sensitivity, specificity, likelihood ratios, and pre- and post-test probability of disease. The next sixty-five chapters are a consideration of the various parts and systems of the body with a discussion of evidence-based signs and maneuvers. Four criteria are necessary to be eligible for diagnostic accuracy in the book: that patients are symptomatic; that the physical sign in the study must be clearly defined; that there must be an independent comparison to an acceptable diagnostic standard which could include laboratory testing, imaging, surgical findings, or postmortem analysis; and that numbers could be extracted to construct a 2 x 2 table and thus calculate sensitivity, specificity, and likelihood ratios. The final and most important chapter in the book is the online only appendix comprising approximately 1,600 individual signs or maneuvers, their likelihood ratios, and the pre-test probability of the disease. The writing is clear, and the material is very well organized. There are many excellent evidence-based tables in the book but no illustrations. Included is a list of forty-five articles that have videos depicting certain signs and conditions that are considered difficult to describe in words. It appears a subscription is needed to watch the videos. There are a sufficient number of pertinent references ranging from the early 19th century to 2023. The index and table of contents are both quite helpful. A major omission of this book is an examination of the skin, including dermoscopy. There are a few isolated references to skin findings, such as spider angioma, scattered throughout the book. The book also leaves out an explanation of the physical diagnostic tools and signs not covered, leaving readers to speculate whether these are not reliable or if evidence-based studies have yet to be conducted.

Assessment
This book is an exceptional contribution to the field of medicine. Placing the appendix online so that it can be accessed on rounds or at the bedside is a vast improvement and is highly needed. This book is highly recommended as a reference to determine if, for example, hearing an S3 gallop or measuring capillary refill time is diagnostically helpful. To optimally utilize this book, readers should already be capable of skillfully performing the tests and appreciating the physical signs themselves.