The clinician’s goal in performing a history and physical examination is to generate diagnostic hypotheses. This was true for Hippocrates and Osler and remains true today. The purpose of DeGowin’s Diagnostic Examination is to encourage a thoughtful, systematic approach to the history, physical examination, and diagnostic process.
The practice of medicine would be simple if each symptom or sign indicated a single disease. There are enormous numbers of symptoms and signs (we cover several hundred) that can occur in a nearly infinite number of combinations and temporal patterns. These symptoms and signs are the rough fibers from which the clinician must weave a clinical narrative, anatomically and pathophysiologically explicit, forming the diagnostic hypotheses. Mastering the diagnostic process requires:
(1) Knowledge: Familiarity with the pathophysiology, symptoms, and signs of common and unusual diseases.
(2) Skill: The ability to take an accurate and complete history and perform an appropriate physical examination.
(3) Experience: From longitudinal exposure to many clinical situations, diseases, and patients, each thoroughly evaluated, the skilled clinician develops familiarity with the presenting symptoms and signs of a wide variety of pathophysiologic processes allowing him to generate a probabilistic differential diagnosis for each new patient.
(4) Judgment: Knowledge of medical science and the medical literature, combined with reflective experience, develops the judgment necessary to efficiently test the hypotheses in the laboratory or by clinical interventions [Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet. 2003;362:1100–1105].
DeGowin’s Diagnostic Examination has been used by students and clinicians for over 40 years precisely because of its usefulness in this diagnostic process:
(1) It describes the techniques for obtaining a complete history and performance of a thorough physical examination.
(2) It links symptoms and signs with the pathophysiology of disease.
(3) It presents an approach to differential diagnosis, based upon the pathophysiology of disease, which can be efficiently tested in the laboratory.
(4) It does all of this in a format that can be used as a quick reference at the “point of care” and as a text to study the principles and practice of history taking and physical examination.
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