It is part of the Art and Science of Clinical Practice. Although I learned it as part of my training in Medicine, the truth is that it is also part of the discipline of Physician Assistants, Nurse Practitioners, Physical Therapists, Respiratory Therapists and others in the allied health professions. As clinical folk, we are all observers, and we are taught to observe critically and to use our observations to guide our actions. As an Internist, I spent a good portion of my years in clinical training honing my skills in physical diagnosis.
The practice of physical diagnosis involves training the senses to do their tasks critically, and to train the mind to interpret those inputs rigorously. To wit, all of us look, but we do not always see. The untrained eye sees a sweaty person with a thick neck where a trained clinical eye sees a hyperthyroid person with a large goiter. I do not say this to detract from the non-clinician but to instead emphasize that all clinical experts begin as untrained – me and all of my colleagues among them. In clinical training we learn to use each of our senses as sources of critical diagnostic information.
The Eyes:
We learn that our eyes tell us about the appearance of things and also the behavior of things. We learn to look for nuance and subtlety – the shape of a thing, its color, its margins, and its three-dimensional appearance. We learn to look for effacement of natural lines, for unexpected shapes and other distortions of what we have learned to be normal. This is how we identify deformity, induration, edema, and other visual evidence of things “not okay.” I have made diagnoses ranging from heart failure to cellulitis to hyperthyroidism using my eyes. My mentors taught he how to do it.
The Ears:
I have a stethoscope. It isn’t the one that I purchased in medical school, used during my residency, and wore around my neck during my years of clinical practice, but this one is just as serviceable. Nothing lasts forever.
The stethoscope provides one form of auditory information. We can listen to a person’s breath, the beating of their heart, the rumblings of their digestive tract, and even the life signs of their unborn offspring. I have diagnosed asthma, heart failure, lung cancer, and infarcted bowel with this simplest of acoustic amplifiers.
But we listen even without tools. I remember the sound of a chest and an abdomen stuck by my righthand middle finger against my lefthand middle finger held tightly against my patient. Where I should have expected a dull thud, I heard a resonant note. Something was not right. Where I expected a resonant note of bowel gas, I heard a dull thud instead. Something was not right. We listen not just with instruments, but with our ears.
The Touch:
Touch is not a simple thing. It is many things. Having experienced a sensory stroke in the last year, I am more aware of the value of touch than I ever was as a practicing physician. Touch provides information from a variety of sensations. Touch tells us about temperature – the heat of an inflamed lesion or an inflamed joint, for example. It also tells us about vibration – the gentle purring of a pet cat or the bruit of a thyroid goiter or a carotid stenosis. It also informs us of pressure echoes such as the ballottement of a liver in a fluid-filled abdomen or a fluid-wave in a similar abdomen.
Sometimes, touch tells us something more subtle but no less important. It informs us of our patient’s fears.
The Scent:
The sense of smell is used in physical diagnosis too. I recall having used it in diagnosing kidney failure and also in cases of gangrenous feet. The scent of cases of acute alcohol intoxication were too many. Among infectious conditions, there are yeasty odors and fishy odors, and odors that recall the smell of tortilla masa. None of them are the scents of health. I remember that Susan once saved a person’s life because she correctly identified the odor of bitter almonds in a mason jar whose contents included sodium cyanide. The patient lived.
Taste:
Well, here we are at the end – taste. You probably recall one or more movies in which interns are challenged to identify the sweet taste of sugar in a diabetic patient’s urine. I assure you that this is not a typical rite of passage in clinical training programs. Let me just say that what most of us experience as flavor is the conflation of olfactory and gustatory sensations. I cannot recall a diagnosis that I ever made on the basis of taste, for what little that matters in this essay.
In Summary:
My reason for pondering Physical Diagnosis this evening is that I had a text exchange this evening with one of my geeky FB buddies who looks at the world of tech in much the way that I do. We were contemplating the role of cancer-detection blood tests and breathalyzer-type cancer analysis tests. Some of these technologies are ready for use and other are not quite ready for prime time. In either case, they are not crazy ideas. They are ideas well-grounded and properly rooted in Physical Diagnosis of the type that your PCP, NP, PA, nurse, PT, RT was trained to use to figure out WTFIGO – What The Fuck is Going On – because we want to help.