Clinical Eye (or Nose)

Written by BPNews Team | 20 November 2011

Back in my internship days, we used to have a standing joke that while a neophyte doctor has to request for laboratory tests to diagnose Appendicitis, a veteran will know the diagnosis once the patient walks into the doctor's clinic. Although this joke is a bit of an exaggeration, in my 21 years of clinical practice, there have been many instances when the joke was proven right.

I am not talking about ESP as in the case of the doctor who will tell you what's wrong with you even before you open your mouth and tell you to pay his professional fee to a statue of Jesus Christ with an open palm. I am talking about what we call a "clinical eye" that is able to discern the subtle nuances of an illness. The way a patient walks, the way a patient points to the part that hurts, or even the way the spouse describes the way the patient sleeps.

For instance, in the case of appendicitis, wherein it is a scandalous for a doctor not to know the sequence of events and their corresponding clinical symptoms, doctors are trained to rely 70% on the clinical history, 20% on the physical examination, and only 10% on the laboratory results. In cases where any of the three do not agree with each other, we have to put weight on their relative importance. In fact, it is possible to diagnose Acute Appendicitis without laboratory tests, but since the patient will have to go under the knife, we have to be doubly certain.

There are fool-proof maneuvers that, when in corroboration with each other, can diagnose appendicitis even before the med tech sleeping in the lab is roused from his blissful sleep. The pain of appendicitis on the lower right abdomen, although painful if pressed on, will be much more painful if you suddenly remove your pressing hand. The patient will limp on his right since standing up straight will make the abdominal muscles press on the swollen appendix (something we have come to call the "lay-pi walk" as in "pilay").

The chest is a multilayered wall of skin, fat, muscle, bone, connective tissue, lung and heart, such that a complaint of chest pain cannot be altogether diagnosed as a heart attack. How a patient describes the pain is a considerable help in the diagnosis. Since pain from the superficial organs tend to be focused on a small area, the patient tends to use a finger to point to it. While for deeper origins of pain that are less distinct, a closed fist or an open palm is used. I have never seen a patient having a heart attack point to his chest with his index finger.

The lungs, although lodged inside the thoracic cage is one of the most accessible organs of the human body. Although the chest is fenced in by bony-hard ribs, it has been designed with wide intercostals spaces that lend easy access to the lowly stethoscope. Even without the need for chest xrays, majority of diseases of the lungs can be diagnosed by simply listening to the breath sounds.

Phlegm in the airways and airsacs give out crackling sounds when the inhaled air passes through it creating tiny bubbles that sound like crumpling paper for large airways, crumpling cellophane for smaller airways and hairstrands rubbing against each other for the airsacs. The sounds created by tapping on the chest can also help in detecting the presence of fluid in the thoracic cavity the way we assess a canister whether it is full or not without opening the lid.

There are instances when not only the clinician's eyes are used. Some infections give out a characteristic odor that can lead to a diagnosis even with eyes closed.

In this ever changing age of technology, doctors in big medical centers are slowly becoming slaves of laboratory equipment. Worse, in a world that's becoming more and more litigious, doctors are slowly becoming paranoid slaves of medical malpractice lawyers.

Few years ago, an uncle asked me to talk to his attending physicians after a simple CT Scan with contrast caused him to have Acute Kidney Failure. As I scanned his chart, I was surprised to see that 70% of the thickness was laboratory results. (So this is what makes this medical center so expensive! They're afraid to make a mistake after making a mistake.)

Whatever happened to the 70%, 20% and 10%? We are being ushered into a new age of medical breakthrough upon medical breakthrough at break-neck speed. But no matter how high-tech medical diagnosis becomes, the good old history taking and physical examination will be here to stay. You wouldn't want your fiancée to attach electrodes on your arms, chest and head before being asked whether you love him/her or not, would you?