Tuesday, 9 October 2007

Arms and Legs

Today this blog features on how doctors examine their patients.

In the main, doctors commence their examination by starting with the Head, Ears, Eyes, Nose and Throat (HEENT). They then progress down to the chest and abdomen to complete their examination. This is the first problem...

If the arms and legs are not examined then the patient clinically has no arms or legs ! By not examining the limbs, the doctor can miss very important physical signs.

Normally, the observations are performed by nursing staff by taking the pulse, blood pressure, respiratory rate, SpO2 and temperature. These readings are normally performed on an automated machine. Here is where the next problem comes in ! By a machine taking the readings the doctor no longer takes the pulse or holds the hands and thereby misses salient clinical signs.

The pulse rate is not the only thing that one looks for when examining the pulse. The quality of the pulse is very important that a machine cannot measure so easily. When I mean quality I mean the strength and dynamics of the pulse e.g. weak pulse or strong pulse. The pulse may be slow to rise during systole or may have a brisk upstroke and then collapse, the former which may may signify Aortic stenosis and the latter Aortic regurgitation respectively. Moreover, a collapsing pulse can also be associated a hyperdynamic circulation as I have previously discussed.

An excellent example was a recent case of a patient with a fever who was being monitored. The pulse rate on the screen said 156 beats per minute. For some patients with a fever, this would not be unusual. However, when the pulse was measured, it was 84 per minute. In fact, when listening to the apex beat, it too was 84 per minute. The machine was wrong ! Yes, the machine made a mistake. Hence, relying on a machine may give you inaccurate information. You must recheck the observations by taking the pulse by hand.

Moreover, failing to check the hands you will miss clubbing, splinter haemorrhages, Janeway lesions, palmar erythema, metabolic palmar flap, so on and so forth, as just a few important examples.

Failing to examine the lower limbs and moreover, failing to remove bandages and socks, you will miss ulcers / infections / gangrene / DVT -- always take off what is covering the skin. In the UK, I saw many cases of severe medical problems being covered over by bandages, socks and even newspaper!!!!

One example was a male patient with a painful lower limb and who was vomiting. On examining his leg, which was covered in newspaper because of the leaking fluid, it was found to be critically ischaemic. The patient was vomiting from septicaemia and needed immediate surgery--which he refused. Other examples have been severe ulceration of the surface tissue down to the bone and a patient with gangrenous toes -- all covered by bandages. Bandages don't make the problem go away, it just makes us want to ignore it. However, when we see a bandage / socks, we should remove them and look at what is there !

Also, in the bed bound patient please check for decubitus ulcers. There was a case of a patient with recurrent fever at a nearby hospital who had no obvious focus. However, when the patient was rolled to the side, a decubitus ulcer was present on the sacrum and culture revealed MRSA. An isotope bone scan was advised to look for evidence of osteomyelitis. Such patients should be nursed on an airbed but failing that, pressure areas should be dressed and the patient turned regularly to offload pressure from such pressure points.

In summary, I would advise doctors to commence their examination by looking at the hands, taking the pulse, and move upwards to the head and then down the body to end at the feet. In so doing, the whole body is examined and simple diagnoses will then not be overlooked e.g. lower limb cellulitis as a cause of fever.

Please consider......