CLINICAL
EXAMINATION
PART 1
LISTEN & WATCH
Since machines have been in use in the
management of medical issues, is clinical examination over for good?
Let’s see how far
patient-doctor relationship and a kind of eye to eye contact can still
challenges machines era.
Let's get started with the
listening step
LISTENING TO
In fact, in medical practice, the art of
listening can be rewarding in many ways.
But, what to listen to?
Patient listening has become obsolete,
people say, but listening to still worth. Listening to the
patient describing his or her illness is instrumental in the making of
the right diagnostic. A good practitioner is first of all a
good listener. Keep in mind that patients are the only people involved in their
suffering. Even crippled , they
can identify the main distressful area and help understand
how the pain itself manifests.
Talking about pain, patients give
valuable clues. Is it a localized pain or a moving one ? Thus , by listening to , a practitioner learns about
the nature of the illness , its schedule, by example the way
gastric and duodenal ulcers, daily or nocturnal fever behave.
Actually, by listening to patients
mapping out their bodies, practitioners draw fine conclusions whether
about GI diseases such as gastric pain related to
ulcers or back pain reflecting pancreatitis or nephritis. Uneasiness in the swallowing refers to
esophageal diseases and only affected patients can guide doctors to this
underneath troubled GI tract.
Let’s
remain that appendicitis pain, even accompanied by other symptoms,
represent a classic topic so that the Mc Burney point situated
halfway along the line joining pubic spine to the umbilicus, serves to
settle its diagnostic. The same goes for gallbladder diseases when
patients describe their pain traveling up to the shoulder. Shoulder pain in
fact underlines gallbladder disorders or cholangitis, in particular among
women. It is said by the way that the 4 Fs define gallbladder
illness: Fat, Female, Fertile and Forties.
Breast
diseases also remain a good example. Breast tumor is first at all a
patient discovery. How tumors behave would be pivotal in the following steps.
Prostate hypertrophy and the toll it takes on the urine flowing and
nighttime sleep. are above all. a patient’s finding. Mastering the
art of listening in medicine pays off most of the time.
WATCHING
Watching your patient also is critical
in settling the diagnostic and later on the treatment. It brings a lot of
information whether in looking at the so-called body language or linking
gestures to what you’re listening to. Over time, practitioners improve their
senses (attuned them), acquiring a kind of clinical intuition named clinical
finesse. It was said that an obstetric maiden could forecast the sex of unborn
nothing but by hearing the parturient crying. The same goes for an
extinguishing physician’s race famous for their accurate diagnostic.
Watching thus is rewarding. Observe your
patient everywhere. Note the color of the eyes, turning whiter in case of
anemia. Also note the face’s asymmetry when Bell’s palsy or even a minor stroke
is there. Asthmatics present with a tightening of the nostrils when fighting
asphyxia or gasping for air. Lips turning to violet and blue herald
deep-troubled blood circulation. Try to observe how pupils react to light.
Opium overdose or cocaine make pupils pinpoint while other narcotics cause
midriasis, or pupil dilatation. If cervical veins dilate, think
about heart problems. The JVD is a hallmark of the right heart
failure. Remain aware of some by sternum noise or murmurs revealing
an underneath cardio vascular disorder.
Watching completes listening by adding
what scientists, practitioners have learned over the years. If by
listening we stand by hypothesis or probabilities range, watching would confirm
or reject these presumptions. Chest area refers to lungs and heart
as well. Esophageal disorders, gastric and mediastinum tumors also
express themselves over there. Collateral circulation, sweating, hoarseness
occur at the level of cervical dermatomes, like in the Horner’s syndrome. Fruit
odor breathing announces
the incumbent keto-acidosis in diabetes. Pulmonary
abscess is always foul-smelling. High blood pressure sometimes gives a flushing
look to the face, let alone injected sclerotic and even tense eyeball, also a
finding in glaucoma. The saying: good clinicians can read diseases at the skin
level sounds like an aphorism.
Observation can reveal the classical
finger tremor of alcoholics deprived of vitamin B1, the exophthalmia of thyroid
disorders. Ascites and the ensuing Caput Medusa refer to portal
hypertension and subsequent esophageal varies ready to rupture.
Skin change, whether by its discoloration or strength leads to blood, hydration and deep located disease. Pancreas cancer gives a yellow hue to the skin. Limbs become sometimes part of the clinical picture. Phlebitis, calf pain, edema add to the clinical status of older patients plagued with abdominal tumors.
Keep also in mind that from the head to
the toes ailments used to take a toll. Alopecia or loss of hair, nail fragility
and discoloration represent only the visible part of the iceberg. Heart and
lung diseases express themselves at the fingers and nails, the so-called
spoon nails of the French doctors. Sometimes a remote detail comes up longtime
before people looks for medical assistance. That’s why patients and doctors need a throughout clinical examination. Medical examination has a lot to do with
patience, that is to say, time.
(To be continued ) FOOTNOTES
Some investigators end up to these
conclusions regarding clinical examination in the making of diagnostic compared
to lab process and other devices :
The authors’ conclusion: “We found that
more than 80% of newly admitted internal medicine patients could be correctly
diagnosed on admission and that basic clinical skills remain a powerful tool,
sufficient for achieving an accurate diagnosis in most cases.”1 This conclusion
made me happy.
However, an editorialist raised
some interesting points. Like me, he is a senior clinician, that is, a
euphemism for older (he was a fellow in the 1950s, I was in the 1970s). He went
further, suggesting “modern imaging techniques when used appropriately have
made the diagnosis of the patient’s disease and management more timely and
accurate. There is also no doubt that these imaging techniques are overused …
these techniques increase the cost of medical care significantly.
”
Older clinicians rely on the history and
physical to a greater degree than younger clinicians. In fact, has the pendulum
swung too far toward technology? As a result of eroding auscultation skills,
many recent graduates can only make cardiac diagnoses by echocardiography.
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