Symptom to Diagnosis An Evidence Based Guide, Fourth Edition

Book Preface

Our goal in creating Symptom to Diagnosis was to develop an interesting, practical, and informative approach to teaching the diagnostic process in internal medicine. Interesting, because real patient cases are integrated within each chapter, complementing what can otherwise be dry and soporific. Informative, because Symptom to Diagnosis articulates the most difficult process in becoming a physician: making an accurate diagnosis. Many other textbooks describe diseases but fail to characterize the process that leads from patient presentation to diagnosis. Although students can, and often do, learn this process through intuition and experience without direct instruction, we believe that diagnostic reasoning is a difficult task that can be deciphered and made easier for students. Furthermore, in many books the description of the disease is oversimplified, and the available evidence on the predictive value of symptoms, signs, and diagnostic test results is not included. Teaching based on the classic presentation often fails to help less experienced physicians recognize the common, but non-classical presentation. This oversight, combined with a lack of knowledge of test characteristics, often leads to prematurely dismissing diagnoses.
Symptom to Diagnosis aims to help students and residents learn internal medicine and focuses on the challenging task of diagnosis. Using the framework and terminology presented in Chapter 1, each chapter addresses one common complaint, such as chest pain. The chapter begins with a case and an explanation of a way to frame, or organize, the differential diagnosis. Diagnostic algorithms are presented that give the learner a way of working through the diagnostic process. As the case progresses, clinical reasoning is clearly articulated. The differential diagnosis for that particular case is summarized in tables that delineate the clinical clues and important tests for the leading diagnostic hypothesis and important alternative diagnostic hypotheses. As the chapter progresses, the pertinent diseases are reviewed. Just as in real life, the case unfolds in a stepwise fashion as tests are performed and diagnoses are confirmed or refuted. Readers are continually engaged by a series of questions that direct the evaluation.
Symptom to Diagnosis can be used in three ways. First, it is designed to be read in its entirety to guide the reader through a third-year medicine clerkship. We used the Core Medicine Clerkship Curriculum Guide of the Society of General Internal Medicine/Clerkship Directors in Internal Medicine to select the symptoms and diseases we included, and we are confident that the text does an excellent job teaching the basics of internal medicine. Second, it is perfect for learning about a particular problem by studying an individual chapter. Focusing on one chapter will provide the reader with a comprehensive approach to the problem being addressed: a framework for the differential diagnosis, an opportunity to work through several interesting cases, and a review of pertinent diseases. Third, Symptom to Diagnosis is well suited to reviewing specific diseases through the use of the index to identify information on a particular disorder of immediate interest.
Our approach to the discussion of a particular disease is different than most other texts. Not only is the information bulleted to make it concise and readable, but the discussion of each disease is divided into 4 sections. The Textbook Presentation, which serves as a concise statement of the common, or classic, presentation of that particular disease, is the first part. The next section, Disease Highlights, reviews the most pertinent epidemiologic and pathophysiologic information. The third part, Evidence-Based Diagnosis, reviews the accuracy of the history, physical exam, laboratory and radiologic tests for that specific disease. Whenever possible, we have listed the sensitivities, specificities, and likelihood ratios for these findings and test results. This section allows us to point out the findings that help to “rule in” or “rule out” the various diseases. History and physical exam findings so highly specific that they point directly to a particular diagnosis are indicated with the following “fingerprint” icon:
FP = fingerprint
We also often suggest a test of choice. It is this part of the book in particular that separates this text from many others. In the final section, Treatment, we review the basics of therapy for the disease being considered. Recognizing that treatment evolves at a rapid pace, we have chosen to limit our discussion to the fundamentals of therapy rather than details that would become quickly out of date.
The fourth edition has been completely updated through a comprehensive review of the relevant literature and many chapters have undergone substantial revisions by new authors. Changes include new algorithms and approaches in the chapters on Chest  Pain, Syncope, Dizziness, and others. Recently developed new diagnostic tools are discussed in the chapters of Diarrhea, Jaundice, and Cough and Fever, and new guidelines have been included in the chapters on Screening, Diabetes, and Hypertension.
For generations the approach to diagnosis has been learned through apprenticeship and intuition. Diseases have been described in detail, but the approach to diagnosis has not been formalized. In Symptom to Diagnosis we feel we have succeeded in articulating this science and art and, at the same time, made the text interesting to read.

Scott D. C. Stern, MD Adam S. Cifu, MD Diane Altkorn, MD