Section A

General Neurosciences

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I had the good fortune of being at the National Institute for Nervous Diseases (as it was then named) at Queen Square for a year (1974–1975). Dr. Godfrey Hounsfi eld had just intro-duced the EMI scanner (named after Electric and Musical Industries Ltd.) and it was in use at Atkinson Morley’s Hospital in Wimbledon and at Queen Square. Already, the senior clini-cians at Queen Square were voicing concern. The ease with which the living brain could now be studied on the computer images was leading to indiscriminate demands for scans after cur-sory clinical assessment. Atrophy of the clinical senses was greatly feared.

Since then we have seen the mushroom-ing of magnetic resonance scanners, positron emission tomography scanners, and a host of other diagnostic devices capable of produc-ing mind-blowing images showing the struc-ture and function of the human brain and spinal cord.

This chapter ponders the downside of these unquestionable advances and urges careful clinical examination and analysis before using them (Fig. 1.1).

In doing so, this chapter attempts to put into practice the prescription written in 1927 by Dr. Francis Peabody.1

It is probably fortunate that systems of edu-cation are constantly under the fi re of general criticism, for if education were left solely in the hands of teachers the chances are good that it would soon deteriorate. Medical educa-tion, however, is less likely to suff er from such stagnation, for whenever the lay public stops criticizing the type of modern doctor, the medical profession itself may be counted on to stir up the stagnant pool and cleanse it of its sedimentary deposit. The most common

The Relevance of Clinical Examination Today1

criticism made at present by older practition-ers is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine—or, to put it more bluntly, they are too “scientifi c” and do not know how to take care of patients.

In the present instance we should substi-tute “sophisticated tests” for “the mechanism of disease.” If, perchance, you have not yet read this classic article, I urge you to look for it in the library and embrace the lessons taught by this wise physician.

Dangers of a Slipshod ExaminationA cursory examination yields few clues to diag-nosis and leads to the use of shotgun tests. As with the actual shotgun, most of the pellets

Sunil K. Pandya

Fig. 1.1 Dr. Francis Peabody (1881–1927).

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General Neurosciences4

will be wide of the mark and miss the target. Worse, you may hit innocent “lesions” with dis-astrous results.

Let me give you an example of how tests can be avoided using the “little gray cells.”2

Some years ago, while I worked at the King Edward Memorial Hospital and its allied medi-cal college in Mumbai as a neurosurgeon, I received a phone call from a senior colleague in the Department of Endocrinology. He was wor-ried he might have suff ered a stroke in his right parasagittal parietal lobe a few minutes earlier.

He told me of how he had awakened as usual, and after his bath and breakfast, got dressed to come to hospital. As he descended the stairs in his home, he noted the foot drop on his left side.

He came over to our outpatient clinic at my request. He was composed, narrated his history without diffi culty, and awaited recommenda-tions for tests and treatment. His own diagnosis would have necessitated urgent computed tom-ography or magnetic resonance scanning and preparations for lysing a presumed thrombus using intravenous tissue plasminogen activator.

Examination showed a simple foot drop with no other signs. The plantar response could not be assessed but the ipsilateral knee refl ex showed no abnormality. The fi ndings did not appear to be the consequence of a stroke. I was puzzled about the cause of his foot drop and why it should occur while descending stairs.

I asked him if he could have inadvertently exerted pressure over the lateral popliteal nerve. After a little refl ection he conceded that it could have happened for he often slept on a couch with his knee dangling over the edge of the back of the couch. Yes, he had slept thus the previous night. And yes, it was the knee on the same side as the foot drop that had rested on the back of the couch.

So that might explain the compression of the nerve, but why should the foot drop while descending stairs.

Examination had shown weakness of the extensors of the toes and foot but some power persisted. A thought came to mind and I looked

at his shoes. They were somewhat heavy. I asked him to walk on the level fl oor of the clinic with-out the shoes. Did the foot drop persist? His face was fi lled with surprise. “The foot is much bet-ter. The weakness is much less marked.”

He was now asked to put on his shoes and repeat the walk. “Ah! It is diffi cult to keep the foot up when stepping with the shoes on.”

I now asked him to descend the stairs out-side the clinic and could almost hear “Eureka!” going through his mind as relief fl ooded his face.

Subsequent examination by our neurophy-sician and electrophysiological examination confi rmed incomplete paralysis of the lateral popliteal nerve, most likely from pressure. Helped by physiotherapy, he recovered com-pletely over the next few weeks.

Current high resolution scanners show us a wide range of variations in anatomy and physi-ology. On several occasions, these are not the cause of the patient’s symptoms and, left alone, may do no harm. If, however, we have no clue as to the possible diagnosis, we may fasten on to them, investigate by further tests and even oper-ate upon them without any benefi t and some risk to the patient. The presence of a parasagit-tal meningioma measuring 1.5 cm in a 70-year-old patient with limb weakness is an example. Careful clinical examination would have shown spondylotic myelopathy as the culprit.

We are being made increasingly aware of the possible dangers of some tests. Medical journals and the media express concern about the radiation risks from tests such as repeated computed tomography scans.

Listening to the PatientSir William Osler (Fig. 1.2), who ended his career as Regius Professor of Medicine at Oxford, kept emphasizing to his students, “Lis-ten to your patient, he is telling you the diag-nosis.”3 Indeed, when treating patients with diseases of the nervous system, the detailed history, obtained painstakingly, more often than not, yields the diagnosis.

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5The Relevance of Clinical Examination Today

Unfortunately, listening requires time and eff ort. The chaff has to be separated from the grains and the clinician must overcome irrel-evant digressions, emphasis by the patient on points that are of little signifi cance and at times, the off ering of diagnoses by friends and relatives and concealment of information. The rewards outweigh the expenditure of time and eff ort.

My teachers have taught me to analyze the details gathered after concluding the ses-sion on history-taking and arriving at tentative conclusions on the nature and location of the disease. This has proved extremely useful and has focused examination of the patient so that further vital clues are unearthed.

The Clinical ExaminationA gentle, thorough, and unhurried examina-tion elicits data that supplement information learned while taking the history. Subtle signs provide vital clues to localization of disease.

The diff erentiation between disease originating in the brain and that in the spinal cord can, at times, be diffi cult and cannot be made only on the basis of history. Failure to make the dis-tinction can mean considerable expense to the patient and delay in diagnosis and treatment.

The AnalysisAssessment of the information gathered by exam-ination may lead to modifi cation or even change in the diagnosis made after taking the history. Certainly, the mind is clearer on the likely cause and site of the disease troubling the patient.

Based on this assessment it is possible to discuss the likely diagnosis with the patient. This can often help assuage the anxiety that has troubled the patient since the awareness of an illness. The likelihood of a self-limiting condi-tion that needs no tests and simple treatment lifts a huge burden. The possibility of spondy-lotic myelopathy or a benign tumor amenable to surgery similarly helps ridding the patient of worry of dreaded malignant cancer.

This discussion paves the way for identifi ca-tion of tests and an explanation of the rationale for them.

There is another important consequence. Taken together, history-taking and the exami-nation add to the building of the doctor–patient relationship and healthy interaction with wor-ried family members. Witness to the care and concern displayed by the clinician, the patient, and family members develop faith. Faith is the vital ingredient that cements trust in the doc-tor and is a keystone in the care of the patient.

Assistance to Those Performing TestsThe provision of information gained from his-tory and examination and the subsequent anal-ysis by the clinician that led to a provisional diagnosis is invaluable to those performing the special tests requested. Dr. Anisha Tandon makes an impassioned statement.

Fig. 1.2 Sir William Osler (1849–1919).

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General Neurosciences6

We radiologists are familiar with the experi-ence of having to report radiological studies with absolutely the bare minimum clinical history or the complete lack of it. But what has begun to shake me to the core is the fact that even when I have gotten back to the refer-ring clinician for more information, there have been innumerable instances where they sim-ply do not know more just because they have not really talked to the patient in detail, leave alone examined the patient.

She goes on to describe a patient referred to her “to exclude cerebral venous thrombo-sis.” Her fi ndings showed metabolic encepha-lopathy. Subsequent tests showed a probable cancer in a cirrhotic liver and ascites—not iden-tifi ed on clinical examination.4

Do Other Factors Play a Role?Dr. Tandon’s experience, referred to above, makes one ponder the reasons for jettisoning the invaluable heritage of meticulous clinical examination. Dr. Ingelfi nger, the much-respected editor of the New England Journal of Medicine, felt that the personal encounter between the patient and the physician can be marred by authoritarianism, paternalism, and dominance coupled with arrogance on the part of the latter. In his posthumous essay titled Arrogance he provided a personal example of the suff ering caused by such behavior on the part of his medical attendants.5

ConclusionThere was a time when physicians prided them-selves on their powers of observation and deduc-tion. Sir Arthur Conan Doyle modeled Sherlock Holmes on his teacher, Dr. Joseph Bell (Fig. 1.3).

The oft-narrated anecdote will bear repeti-tion: On one occasion Doyle witnessed Bell tell-ing students that a new patient walking into the outpatient clinic was a recently discharged non-commissioned offi cer who had been serving in a Highland regiment stationed in Barbados. Bell went on to explain,

You see gentlemen, the man was respectful but did not remove his hat. They do not in the army, but he would have learned civilian ways had he been long discharged. He has an air of authority and is obviously Scottish. As to Bar-bados, his complaint is elephantiasis, which is West Indian, and not British.6

We need to bring back into the medical cur-riculum and into our own practices the art of observation, listening, and the careful exami-nation of the patient.

Dr. Bell, himself, was concerned about the development of these in impressionable medi-cal students.

In teaching the treatment of disease and acci-dent, all careful teachers have fi rst to show the student how to recognize accurately the case. The recognition depends in great meas-ure on the accurate and rapid appreciation of small points in which the diseased diff ers from the healthy state. In fact, the student must be taught to observe. To interest him in this kind

Fig. 1.3 Dr. Joseph Bell (1837–1911).

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7The Relevance of Clinical Examination Today

of work we teachers fi nd it useful to show the student how much a trained use of the obser-vation can discover in ordinary matters, such as the previous history, nationality, and occu-pation of a patient.

He made these suggestions before the dis-covery of X-rays by Roentgen. They are even more relevant today.

Closer interaction between physician and patient at all stages of care can be placed on a fi rm footing by the concern shown during the fi rst encounter; and what better way is there of showing such concern than by taking a careful and unhurried history and carrying out a thor-ough physical examination? These benefi t both the patient and the physician.

References

1. Peabody FW. The care of the patient. JAMA 1927;88:877–882

2. Hercule Poirot. http://en.wikipedia.org/wiki/Hercule_Poirot Accessed September 19, 2013

3. Osler William. http://open.salon.com/blog/amytuteurmd/2008/11/19/listen_to_your_patient Accessed September 17, 2013

4. Tandon Anisha Sawkar. The vanishing art of clinical science – hyposkilia. http://radiologystories.com/2013/06/03/the-vanishing-art-of-clinical-science-hyposkilia/ Accessed July 8, 2013

5. Ingelfi nger FJ. Arrogance. N Engl J Med 1980;303(26):1507–1511

6. Anonymous. The real Sherlock Holmes? http://www.sherlockandwatson.com/the%20real%20sherlock%20holmes.html Accessed September 19, 2013

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