|Year : 2021 | Volume
| Issue : 2 | Page : 113-120
“Art at its Heart” “The Golden Art of History and Clinical Examination”
Tammiraju Iragavarapu1, Gautham Sunkarapalli1, Sushma Vutukuru2, Aniket Vasanth Kataria1
1 Department of Cardiology, ASRAM Medical College, Eluru, Andhra Pradesh, India
2 Department of Pathology, ASRAM Medical College, Eluru, Andhra Pradesh, India
|Date of Submission||04-Jun-2021|
|Date of Decision||08-Jul-2021|
|Date of Acceptance||12-Jul-2021|
|Date of Web Publication||31-Aug-2021|
Associate Professor, Department of Cardiology, ASRAM Medical College, Eluru, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: History taking and physical examination have been rendered as the most valuable, cost effective reliable skills taught during medical education which reward the clinicians, the satisfaction of making a diagnosis, while building a natural bond of human touch with the patient. Aims and Objectives: A proper and judicious choice of investigations guided by logical reasoning which was made after integrating the history and physical exam is crucial for timely diagnosis and appropriate management. Materials and Methods: We report a series of 11 cases which were mismanaged in the early stages due to lack of proper history and physical examination. Results: Though these cases appear to be simple, they highlight the proper methodical and systematic way of approach to the patient care which helps in preventing unnecessary investigations and improper management. Conclusions: Excessive worshipping of newer diagnostic modalities will lead to a more “computer oriented” approach rather than a patient centered one.
Keywords: Hi-tech, history, human touch, mismanagement, physical examination
|How to cite this article:|
Iragavarapu T, Sunkarapalli G, Vutukuru S, Kataria AV. “Art at its Heart” “The Golden Art of History and Clinical Examination”. J Pract Cardiovasc Sci 2021;7:113-20
|How to cite this URL:|
Iragavarapu T, Sunkarapalli G, Vutukuru S, Kataria AV. “Art at its Heart” “The Golden Art of History and Clinical Examination”. J Pract Cardiovasc Sci [serial online] 2021 [cited 2021 Dec 1];7:113-20. Available from: https://www.j-pcs.org/text.asp?2021/7/2/113/325227
Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.
Sir William Osler, Father of Modern Medicine 1849–1919.
The student should never be allowed to forget that it takes a man, not a machine, to understand a man.
Allen, RB: The Commonwealth Fund; 1946.
| Introduction|| |
The term physical examination has existed for ages, has different meanings and inferences in different eras based upon the prevailing medical knowledge during those times, and has undergone several modifications with the dynamic medical knowledge. Physical examination is the physician's route of assessing a patient using the five senses and minimal invasiveness, which weighs more than the patient.
There is no doubt that the practice of medicine in the present day is not the same as in the last few centuries. Technology is continually redefining the medical practice. Although the modern technology aids better management, the role of careful history taking and physical examination will still remain firmly entrenched in establishing a diagnosis, as the judgmental capacity of investigation results majorly relies upon the inferences drawn from the elaborate history taking and detailed physical examination by a clinician.
Being skilled at conducting a comprehensive clinical assessment, allows a more trusted doctor–patient relationship which is crucial in therapy effectiveness and patient salvation. The present article is a series of interesting cases presented to our Department of Cardiology which is a tertiary care center in India. The key points of the cases in our series were mentioned in [Table 1].
| Case 1–4 Arterial and Venous Occlusion Mimicking Neuropathic Pain|| |
A 34-year-old female presented with weakness, pain, and numbness of the left upper limb from 10 days. She was treated for carpal tunnel syndrome in an outside hospital and then referred to us. On examination, the left upper limb was cold and the peripheral pulses were not felt. Motor power was 4/5. Arterial Doppler and peripheral angiogram showed total occlusion of the left axillary artery with huge thrombus burden [Figure 1]. The patient was found to be in Rutherford Class IIb stage of acute limb ischemia. Thrombus aspiration was done and intra-arterial streptokinase infusion was given for 36 h. The patient was relieved of pain and numbness, except over little finger. She was discharged on oral anticoagulation maintaining international normalized ratio around 2.5. Follow-up peripheral angiogram (PAG) after 3 months showed complete resolution of the thrombus. Another case of a 40-year-old male presented with a 2-month history of intermittent pain, dragging sensation, and paresthesia of the left arm. He is a teacher by profession and reports repeated use of the left hand for dusting blackboard with hyperextension and abduction. He has been treated for few weeks symptomatically elsewhere in terms of neurogenic pain. On detailed examination, there was swelling of the left arm and forearm (>2 cm) compared to the right arm (RA). A color Doppler of the left upper-limb veins revealed thrombosis of subclavian, axillary, and basilic veins [Figure 2]. Hence, the diagnosis of primary upper extremity deep venous thrombosis (Paget–Schroetter syndrome) was made after ruling out other causes. As it was a delayed presentation, we did not subject him for thrombolysis and directly started oral anticoagulant therapy. A repeat Doppler of the left upper-limb veins showed normal flow in the subclavian, axillary, and basilic veins. Another case of a 50-year-old diabetic female, with a medical history notable for hyperlipidemia, presented to an outside physician with a 2-week history of intermittent pain and paresthesia in the right leg that was aggravated on walking. She was treated for lumbar radiculopathy. She came to our hospital in view of worsening symptoms. On physical examination, the femoral and dorsalis pedis arterial pulsations were absent. Arterial Doppler showed thrombosis at the level of the aortoiliac junction extending into the right iliac artery [Figure 3]. As the patient refused hospital stay, she was started on anticoagulants and follow-up arterial Doppler showed resolving thrombus. A 64-year-old male presented with sudden onset of chest pain along with chronic pain in his left upper limb. Electrocardiogram (ECG) showed changes of inferior wall myocardial infarction (IWMI). He was initially examined by a trainee who found that the patient was in hypotension and was treated accordingly for IWMI. Later during careful physical examination, a discrepancy of blood pressure (BP) was noted between the two upper limbs (Rt: 110 mmHg and Lt: 60 mmHg). Hence, a left upper-limb angiogram was done along with coronary angiogram which revealed a left subclavian artery ostial tight stenosis and a lesion in the left circumflex [Figure 4]. Hence, percutaneous transluminal coronary angioplasty (PTCA) to the left circumflex artery and percutaneous transluminal pulmonary angioplasty with stenting were done to the left subclavian artery. Post procedure, left upper-limb BP was more than 100 mmHg.
|Figure 1: Peripheral angiogram showing pre and post percutaneous transluminal pulmonary angioplasty with catheter-directed thrombolysis in left axillary artery thrombosis.|
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|Figure 2: (a) Doppler analysis of the left subclavian vein showing echogenic material (A), no color filling (B), not showing compressibility (C). (b) Follow-up Doppler showing the subclavian vein showing normal spectral waveform.|
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|Figure 4: (a) Left subclavian artery ostioproximal stenosis. (b) Post stenting to Subclavian artery. (c) Pre percutaneous transluminal coronary angioplasty- (LCX) left circumflex artery lesion. (d) Post percutaneous transluminal coronary angioplasty-LCX.|
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A 70-year-old female, schizophrenic patient on antipsychotics presented to the emergency room with complaints of giddiness and abnormal posture. Magnetic resonance imaging (MRI) brain showed small vessel disease and age-related cerebral atrophy. She was diagnosed with drug-induced dystonia and admitted to psychiatric ward. Nearly after 2 weeks, she had another episode while straining for stools. Careful history was taken, which revealed exertional angina and similar episodes of presyncope earlier. Detailed examination showed a late peaking ejection systolic murmur of Grade 4 radiating to carotids with soft aortic component or second heart sound (A2). Echocardiogram disclosed severe degenerative aortic stenosis. She was referred to a cardiothoracic surgeon for aortic valve replacement.
A 45-year-old patient with anterior wall myocardial infarction (MI) and minimal pericardial effusion underwent angiogram through the right radial artery and was scheduled for angioplasty to the left anterior descending artery. On the day before procedure, the cath lab resident felt that the right radial artery is not palpable and hence procedure should be done through the femoral route. The patient was irritable and complained of nausea. Precise examination of pulse revealed that there was fluctuation in pulse which disappeared during inspiration and appeared during expiration in both the limbs amounting to pulsus paradoxus. Echo showed cardiac tamponade. The patient had pericarditis with minimal effusion which might be due to post MI which led to tamponade. Immediate pericardiocentesis was done and angioplasty was done at a later date through the right radial artery.
An 82-year-old male, IWMI patient presented to the emergency room who on examination had a pan systolic murmur. Echo showed 3–4 mm apical ventricular septal defect (VSD) with near-normal pulmonary artery pressures. He was diagnosed with IWMI complicated by VSD. Initial plan was to go for revascularization and closure of septal defect (surgery/device). On the following day, detailed history revealed that the patient was told to have a small defect in his heart since birth and advised to undergo surgery, but he did not undergo further management as it was not bothering him much. Angiography revealed single-vessel disease, and the patient underwent PTCA with conservative management to the VSD.
A 6-year-old boy almost did doctor shopping for his unresolved fatigue, loss of appetite, and constitutional symptoms for 6–8 months. He was started on various medications empirically including antitubercular drugs in various hospitals in view of pyrexia of unknown origin (PUO). The unresolving constitutional symptoms made him to go around a lot of hospitals. We performed a thorough clinical examination and found an additional heart sound and a diastolic murmur, which was varying with position in the left parasternal area. Echo revealed along polypoidal mass in the right atrium [Figure 5]. He underwent surgical resection of the mass and histopathology confirmed it to be a myxoma.
|Figure 5: (a) Two-dimensional echo four-chamber view showing large polypoidal mass traversing the tricuspid valve with calcifications (arrow). (b) Modified short-axis view showing large mass measuring 6 cm × 4 cm. (c) Intraoperative image of excision of right arm myxoma. (d) Excised right arm myxoma, postoperative image.|
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A 45-year-old male presented to the ENT department with a history of hoarseness of voice since 6 months and shortness of breath NYHA Class II. He underwent fiber-optic laryngoscopy that revealed left vocal cord palsy. Initially, he was evaluated on lines of lung lesion compressing the neural structure because of breathlessness. But later on auscultation, there is a long mid-diastolic murmur which leads to the diagnosis of Ortner's syndrome (mitral stenosis with hoarseness of voice due to compression of the left recurrent laryngeal nerve by enlarged left atrium and pulmonary artery) confirmed by echocardiography [Figure 6].
|Figure 6: Two-dimensional echocardiogram parasternal long axis view (PLAX) showing left atrial dilatation measuring 5.89 cm. (b) Pulmonary artery dilatation measuring 3.9 cm (PSAX). (c) Video laryngoscope images showing the absence of movements of the left vocal cord (left cord palsy). Black arrows pointing left vocal cord.|
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| Case 10 and 11 Excessive Dependence on Investigations|| |
A 60-year-old obese female with OA knee was scheduled for total knee replacement. ECG was done elsewhere and was sent to our department for IWMI changes. She was rushed to cardiac unit and was ordered for an echo, troponin, and posted for angiogram. She denied angina or breathlessness. Echo was normal. Careful look at ECG revealed limb lead reversal of the right arm and left leg which mimics IWMI changes [Figure 7]. A 42-year-old alcoholic, smoker, diabetic male presented with exertional shortness of breath (SOB) and severe burning sensation of the left side of the chest radiating to the back. He was evaluated initially by ECG, echo, and tread mill test TMT in view of his high pretest probability of atherosclerotic disease, but all were within normal limits. Later, when we looked at his chest, there were mild reddish lesions which later progressed to vesicles (shingles) suggesting herpes zoster [Figure 8]. Breathlessness was due to anxiety associated with severe painful lesions which prevented him from taking deep breaths on exertion. [Table 2] summarizes the “caveats behind mistaken diagnosis” in our case series.
|Figure 7: (a) Pre electrocardiogram of lead reversal of right arm and left leg mimicking inferior wall myocardial infarction (arrows in leads II, III, avF. But lead avR is upright). (b) Post electrocardiogram with correctly placed leads (arrow in lead avR).|
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|Figure 8: Shingles (suggestive of herpes zoster) on the posterior aspect of the left side of the trunk.|
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| Discussion|| |
Listen to the patient, he is telling you the diagnosis.
Sir William Osler, Father of Modern Medicine 1849–1919.
The practice of medicine is dynamic. The clinical medicine during the 18th century mainly depended upon the Hippocratic theory to listen to the patient's history and fit the symptoms into an idealized theory of disease. During the 19th century, with medical innovation, several present-day clinical instruments such as stethoscope, sphygmomanometer, and mercury thermometer were invented and introduction of auscultation and objective BP measurement in clinical medicine had occurred.
In the 20th century, various investigation modalities such as specimen examination and analysis, application of Roentgen waves in medical diagnostics and ECG gained popularity. These advances exerted a powerful pull on physicians, drawing them away from the bedside into the laboratory. Laboratory data started challenging the importance of the spoken history of symptoms and the perceived history of signs of a disease.
The expected outcomes of the clinical assessment are a radical understanding of patients, the impact that the disorder has on their working, social life, and also on their general well-being. Precisely for the clinician, the examination should reveal the psycho-physical-social processes underlying the patient's disorder and helps to uncover early what's working and what's not for the patient's life.
In a study done on history taking and physical examination in a primary care setting, 88% of all diagnoses were established by the end of the initial history and clinical examination and similar results have been observed in a general medicine clinic., It is now estimated that between 70% and 90% of medical diagnoses are often determined by the history alone, which is not only an oldest but also a most reliable diagnostic skill. In a follow-up study conducted by Martina et al., physicians correctly classified 93% of patients with abdominal pain and 98% of patients with chest pain as having either an organic or nonorganic etiology solely on the basis of their initial clinical judgment and before ordering any diagnostic tests.
Various recent studies have documented that the decline in physical examination skills among physicians is due to improvements in technology, time constraints, and uncertainty in approaching a diagnosis without relying on investigations, moving from high-touch medicine to hi-tech medicine.,
In a study, it was stated that hospitalists spend <18% and internal medicine interns <12% of their time in direct patient care., The mastery of examination skills at every level of training has decreased over the years., In a pilot study done to assess the clinical skills in internal medicine residency, the score of the residents was <60% on average. This was particularly more worse with cardiovascular and musculoskeletal scores which were significantly lower than other systems. In a data-based measurement of medical errors due to inadequacies in the physical examination, Verghese et al. have published a collection of 208 occurrences and their consequences. The cause of the oversights in the 208 responses has been most often a failure to perform the physical examination at all (in 63%). In our case series, even though it is difficult to segregate, we found that, in 54% (6 out of 11) of the cases, improper examination and, in the remaining 46%, both improper history and examination lead to delay in proper diagnosis and initial mismanagement.
The delay in arriving at the correct diagnosis and delivering proper management varied from 2 days to 2 months in our series. In two of our cases (case 1 and case 4), the discrepancy in both limb pulses was overlooked, which was earlier discussed by De Roeck et al. in their study of coronary-subclavian steal syndrome. Similar misdiagnoses of aortoiliac occlusion were reported earlier in the setting of Leriche syndrome (aortoiliac occlusion) mimicking cauda equina symptoms. Mistaking syncope in patients of aortic stenosis with other cases was described by Goliasch et al. and Coleman et al. Post MI, pericarditis leading to pericardial effusion with tamponade is rare but described in the literature. The case of an octogenarian with MI and congenital VSD was also earlier reported by Tayama et al. Ma et al. reported a similar case of RA myxoma presenting as PUO and constitutional symptoms. In one of our cases, improper ECG lead placement which was overlooked led to unwanted stress to the patient which is an example of too much reliance on investigations which was explained in detail in their study by Rudiger et al. The classical symptoms of Ortner's syndrome which were missed due to improper history and examination were early mentioned by Shariff et al. Undue importance to the investigation and lack of proper clinical examination which led to the improper diagnosis of unstable angina in a case of shingles was earlier reported by Kristine Arthur MD.
But here, we need to consider a couple of limitations of history and examination. The first one is that the patients might not give complete and proper history because of anxiety, social issues, or language barriers. The classical findings pertaining to diagnosis may not appear at the time of the examination which may prevent the physician to make a correct diagnosis without the help of various recent diagnostic modalities with good sensitivity and specificity (like positron emission tomography [PET], computed tomography [CT], and MRI). Hence, we require a knowledgeable and properly trained mind which guides the skill of proper history taking and appropriate examination.
The cumulative compilation of history and examination with the necessary investigations is required in this era, as the modern-day medicine is an evidence-based medicine. If the primary and secondary care physicians have good clinical skills, the tertiary care physician will rely on the findings of these earlier diagnosticians and tend to proceed from there taking the advantage of selective investigations or procedural skills. The earlier diagnostician whom the patient approaches initially should better make a clinical diagnosis and refer the case to the concerned doctor if needed as early as possible to avoid unnecessary delay as seen in most of our cases. The advantages of this approach enhance doctor–patient relationship, improved patient safety, fewer diagnostic errors, and lower financial burden. The Pyramid depicting the hierarchy in making a management decision is shown in [Figure 9].
|Figure 9: Pyramid depicting hierarchy (bottom of pyramid to top of pyramid) in making a management decision.|
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Physical examination looks more not only into the patient body but also his emotions more than any CT/MRI/PET scans. This data analysis basing more on investigations generates a virtual e-patient rather than a real patient which may hinder the doctor–patient bonding. No doubt, In these days of more and more consumer issues leading to much strained doctor patient relationship, Covid pandemic, the medical fraternity should take all the necessary endeavors to safeguard their dignity and safety. Hence, we need to have a balance between the older golden art and the newer sophisticated tools to do justice to the patients, particularly in a developing country like ours where many investigations are not available in rural areas.
Moreover, the diagnostic value of detailed history and clinical examination should be elaborated in the medical curriculum of training pupils in order to incorporate the integrated approach at that primitive level itself as the perfection of physical examination skill requires continued efforts and practice.,, Insights should be drawn on giving weightage to clinical skills before admission into postgraduate degree and also in CME accreditation.
The emphasis of history and examination and their importance in medical curriculum by various authors in the past 40 years were summarized in [Table 3].
|Table 3: Various studies emphasizing the importance of history and clinical/physical examination|
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| Conclusions|| |
Perhaps, the fusion of good history, physical examination, and appropriate investigations render the physicians to become more accurate, quicker diagnosticians and health-care providers while maintaining the crucial human bond forged through personal interaction, thereby improving the general patient care and safety. Hence, the art of history taking and clinical examination should tend paramount importance within the medical curriculum and their practice should be inculcated into the training medical pupils.
Although the need of the hour and present day scenario in an Intensive care setup is more dependent on investigative profile, what matters deeply to a critically ill patient, which comforts him more than any hi-tech scan is the human touch which he hopes as the divine touch which takes him through his terminal illness and brings him out of it.
Ethical clearance was taken prior to the collection of cases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3]