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It was a Tuesday morning, 10am. Our group was reporting back to our staffman (Morley Lertzman) on the respirology consult service of St Boniface Hospital (Winnipeg). I mentioned I had an interesting young lady was waiting to be reviewed. Without any further discussion, we put down our teacups (yes, he was unique!) and went to her bedside. Mandy was 29, indigenous, and unencumbered by medical paraphernalia. Dr Lertzman took her pulse, thought for a moment, and said:
"I suspect she has mitral stenosis, mitral regurgitation and aortic incompetence".
Each of us in the group looked at one another, somewhat surprised.
"How did you know?"
"Well, she is in atrial fibrillation, likely rheumatic at this age. Most likely based on structural disease of the mitral valve - see, she has a malar flush. And if it's stenotic, it's likely regurgitant. The AR is easy, she has a collapsing (Corrigan's) pulse. If she was a hospitalised cardiomyopath, she might be on oxygen, have a heplock, or have dilated neck veins - not so."
The echo from the previous day was confirmatory. I never forgot that lesson.
In previous articles, I have referred to my career exemplar, John Dagg, who could help a group of novice medical students diagnose a patient's right-sided Pancoast Tumour with associated Horner’s syndrome - and an ipsilateral cerebellar metastasis - just from observation. Or put 2 and 2 together when a 30-year-old man - on the Hematology ward - presented with a swollen knee. Hemophiliac hemarthrosis.
And Conan Doyle, who spied a mildly jaundiced, diaphoretic, tanned sailor in the waiting room, his hand over his upper abdomen. Amoebic liver abscess.
Or my wife, out on a beach picnic, noting a hairy patch over a friend's lower back. Spina bifida occulta.
Now that we are doing telemedicine, and examining actors in the fellowship exam, how much are we missing? I hear we cannot move forward with acute appendicitis until the CT is available. Is observation a thing of the past?
I was an examiner at the Royal College exams one year, and a candidate (from a US school) was asked:
"Can you show us how you examine this man's knee?"
He looked at it, gave it a poke, and said "It looks OK to me."
My colleague and I were hoping for a bit more detail - inspection, range of movement, assessment of ligamentous laxity, balloting for effusion, etc.
"So, what did the MRI show?" he asks.
We gazed at the floor, and moved on.
Or the candidate who put everything together about the young diabetic we gave him.
"And what do you think this red, blistering, dermatomal rash might be on his back?" we asked.
He exited stage left, the patient stage right (to see his family doctor ASAP).
The Royal College exams were a study-in-anxiety ('four years work depends on today's exam') - but nearly everyone who failed their Fellowship Oral had previously failed the Written exam. We really bent over backwards to get their best performance ("get yourself a cup of tea and come back in an hour... "). Good old tea.
For those interested in the power of observation (from a bowler hat), I can recommend the following short story:
‘The Adventure of the Blue Carbuncle’ by Sir Arthur Conan Doyle