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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5233_Библиотеки_им_академика_М_И_Перельмана.pdf
362
A. Farag
The declining interest in clinical examination and relying on modern investigations is spreading like a re in a stack of hey among the new generation of doctors
practicing medicine and surgery. There is a consensus that physical examination
skills have been greatly deteriorating during the past twenty years [2].
Clinical Surgery Save Resources
In an article written in 2018 by Faustinella and Jacobs [2] they presented 3 cases of
misdiagnosis of the case due to the lack of history taking and physical examination5. One of those cases they mentioned is a case of a woman diagnosed of fever
of Unknown origin admitted from the A&E department by the residents. She had an
evident cellulitis in her leg. Apparently she was not examined or even had a history
taking at all.
In my practice I face frequently similar situation where the patient had not been
diagnosed because the examining doctor didn’t ask the relevant question or do the
proper test correctly or even at all.
One of those examples are a case of acute abdominal Pain who presented into my
clinic referred from a senior physician with one week history of acute abdomen and
absolute Constipation. She can walking to my clinic apparently not severely ill “An
important Finding”, walking, talking and breathing normally during History taking
“Another important nding” with history of Left Loin and Left lower quadrant pain
in the abdomen, She had no urinary symptoms “Another important nding” and
absolute constipation since one year. She had Chemotherapy 2years ago for blood
malignancy and recently she is on corticosteroids for autoimmune vasculitis. She
had a battery of blood investigations with normal CBC and Normal white cell
Count. Normal abdominal ultrasonography apart from fatty liver and normal CT
abdomen with contrast.
Her husband told me that few days before presenting to me she had skin rash and
her physician on her follow-up visit didn’t examine this rash and told her most probably it is an allergic reaction to one of the medicine she had. I asked for her permission to examine her and the diagnosis was Simply Varicella Zoster infection in an
immune-compromised patient causing reex ileus (Fig.34.1). I referred her back to
her physician, pain clinics and prescribed a prokinetic medication “Prucalopride”
2mg once per day for her. 12h later she had her rst bowel motion since 1week.
Another case during my clinical rounds diagnosed as a neck.
Mass at the right supraclavicular area in a 30years old male. He Was admitted
since a week waiting investigations including Ct scans. During examination I told
them it is a straightforward hemangio-lipoma. CT proved the diagnosis. They failed
to examine the mass for “Compressibility”, as another example of a diagnosis which
could have be done in any outpatient clinic. It is an example of wasting the resources
in our modern health care systems. Simply due to the lack of clinical skills [2].
34 Conclusion
Fig. 34.1 Varicella Zoster
rash in the patient
mentioned above
363
Clinical Skills Save Lives
The First case as an example is a 5years old boy presented to me when I was a resident in the A&E department in our University hospital accompanied with the resident of pediatrics who diagnosed him as acute appendicitis. When I examined him
he has all the textbook picture of acute appendicitis including tenderness, rebound
tenderness over McBurney’s point and Roving’s sign. I did smell acetone in the
room it was the Child’s breath. I asked for blood Sugar analysis and acetone in
Urine. It was a case of Diabetic ketoacidosis. Without this smell the child may have
died under anesthesia, not only have an un-necessary operation.
The second example In one of the rounds at the out-patient clinic in our University
hospital, I was explaining to the students the value of through though swift general
examination in a 35years old lady who came to repair her post-Cesarean section
incisional hernia, and during her general examination, while feeling her pulse, she
had an unexplained tachycardia 105 per minute, which proved later-on to be a case
of unreported “Asymptomatic” thyrotoxicosis. I she did have the operation directly
she may had a thyrotoxic crisis and even died during surgery [2].
Being Senior Surgeons we are asked to diagnose cases not otherwise diagnosed
since, weeks, months or even years with a lot of un-necessary investigations and
364
A. Farag
un-necessary medications with loss of precious money, working days and Joyful life
for our patients.
I always say “The Key for Proper treatment is the proper diagnosis” which has to
start or can be only veried by our Clinical skills.
If I am responsible for the health care in any part on earth I will not allow any
investigation to be requested without through Clinical examination where the investigations can be ignored if we diagnose the case with 100% accuracy in our Clinic
“Like the case of hemangio-lipoma mentioned above or we can ask for the relevant
investigations in case of DD.Or in preparation for surgery.
References
1. Farag A.Health errors in the era of declining clinical skills and rising whatsapp medicine. Acta
Sci Gastron Disord. 2019;2(7):1–2.
2. Faustinella F, Jacobs RJ.The decline of clinical skills: a challenge for medical schools. Int J
Med Educ. 2018;9:195–7. https://doi.org/10.5116/ijme.5b3f.9fb3.