Geriatric Physical Diagnosis: A Guide to Observation and Assessment

Geriatric Physical Diagnosis is a wonderful new resource offering practical guidance for physical diagnosis and clinical assessment. The text simply and persuasively illustrates the enormous usefulness of an excellently performed physical examination, focusing on timeless fundamentals while offering numerous examples vital to the comprehensive care of older adults.

In the foreword, Williams shares his childhood fascination with puzzles and the magazine Highlights for Children. As a geriatrician, he continues to be delighted by careful observation. He offers varied and numerous examples of how an astute clinician can gather essential data from simple matters such as clothing, self-care, and patterns of shoe wear. From the odor of one's breath to the stains on one's underwear, Williams finds important diagnostic clues that are frequently unrecognized or overlooked.

This comprehensive physical diagnosis textbook is organized by a traditional systems approach, with the addition of several chapters specifically focused on geriatric concerns such as gait and balance, urinary incontinence, and functioning mental status.

The author emphasizes the basics and always illustrates with examples. For instance, in his “Ways to Improve Communication During the Interview” discussion, Williams doesn't just say “speak slowly and clearly” but instead recommends that clinicians not take excessive notes or continually type on a laptop. This book is packed with other practical and feasible suggestions that can allow each physician to do a better job of caring for his or her oldest patients in an effective manner.

Fittingly, Geriatric Physical Diagnosis begins with a chapter on “General Principles,” a sort of guide to attaining a Zen-like state when caring for older adults. Suggestions are offered for achieving the correct examiner psychology, increasing perceptive capacity, creating a healing atmosphere, and recognizing uniqueness, noting that “There is more biologic variability among octogenarians than neonates.” Williams likewise offers real advice on showing reverence for the patient in a manner that is never trite.

One of the more traditional chapters is the section on the respiratory tract system. It goes beyond an exhaustive discussion of examination fundamentals (inspection, percussion, palpation, and auscultation), offering a description of the signs of cavitary lung disease and pleural inflammation as well as techniques for discriminating a pleural effusion from consolidation. Fans of the old television series MacGyver will be impressed with the author's resourcefulness. My favorite example is how to use a large coin (Williams suggests a “pre-1964 silver dollar”) to diagnose pneumothorax.

Beyond the nuts and bolts of examination maneuvers, Williams weaves historical vignettes and anecdotes throughout his text. Trivia buffs and eponym enthusiasts will appreciate the author's remarkable efforts; Dupuytren contracture, the Courvoisier sign, and Perthes test are all in there. Williams also mixes in fun bits of American popular culture to make this a wonderfully readable book. The myriad tables and drawings properly complement the written content. The writing, however, reflects a deep understanding that geriatrics is not simply internal medicine for older adults but that in fact the approach and treatment goals are different. The author's thoughtful approach to physical examination always takes functional status into consideration. The stage is set early, noting the compelling implications for maintaining independence. Although the focus of this book is undoubtedly directed toward geriatrics, the examination basics apply to all patients.

Williams states that “practice does not make perfect; only perfect practice makes perfect.” The wisdom shared in Geriatric Physical Diagnosis can perhaps bring each physician closer to perfection or at a minimum make them better clinicians. By helping identify several specific issues that can help improve geriatric patient care, Williams' work is an important contribution to the broad field of gerontology. He reminds readers that there is still a tremendous amount that can be accomplished without technology, an important lesson in the modern world of virtual medicine. This text is also an excellent resource for anyone involved in medical education. I plan to use this book for my teaching rounds with medical students and carry it on my next overseas journey.

Although the results of every patient satisfaction survey highlight the ability to listen as an important quality of an outstanding physician, patients frequently report that their physicians do not listen to them. Patients, especially older patients, are not necessarily looking for the latest technology or the newest treatment but simply want to be respected, heard, and honored. Geriatric Physical Diagnosis provides an elegant roadmap of how to better accomplish this, using physical examination as a foundation.

Geriatric Physical Diagnosis brings readers back to an era in which the history and physical were fundamental, when medicine was relatively technology free and in its purest form. Perhaps the idea that physicians can observe and examine to gather information is a lost ideal. I think of Williams as a kind of folk hero for those who still believe in the value of old ways—the ones who shun the idea that a physician can simply order an echocardiogram without performing a complete cardiovascular examination. Thanks to Williams, I will now keep an Eisenhower dollar handy, waiting for the opportunity to use it. I look forward to the amazement on everyone's face when, like a magician, I pull it out of my pocket to make the diagnosis.