Signs in Patients…

Answer by Drew Young Shin:

In medical school, students are taught that the examination of a patient starts the minute the patient walks through door well before the physical exam.

Observational skills starts with the way the patient walks:  is there hesitation: is the gait antalgic from underlying pain, or ataxic from a subtle neurological process, or shuffling as an early sign of parkinson’s.  If it’s a child, is the gait festinating (toe-walking)?  or is there double-stepping suggestive of leg length discrepancy.

Visual observations can reveal excessive skin tags which can be xanthomas almost synonymous with hypercholesterolemia.  Yellow pigmented eyes can spin a story of difficulties with alcoholism and liver disease.  Physicians will almost always notice a tremor – is it a resting tremor or a tremor that worsens with use of the hand?  Most pediatricians will be tuned to Acanthosis nigricans – that velvety dark skin pigmentation in the crease of the back of the child’s neck that most parents mistaken for dirt – a precursor for diabetes.

As you introduce yourself, the patient’s breath can be informative – is the breath ketotic that is evident of underlying uncontrolled diabetes.  Halitosis often goes along with gastroesophageal reflux disease.  A thin adolescent woman with bad dentition could be suffering from bullemia as the acidic vomit erodes her teeth enamel over time.

As you reach to shake hands – is he/she right handed or left handed?  Is there an intention tremor or does a pre-existing tremor disappear as he/she reaches for your hand?   Is there train-tracking scars on the non-dominant arm to suggest a history or current struggle with IV drug use.

As you touch to shake hands, is the skin excessively warm (infection, hyperthyroid, carcinoid) or inappropriately cool (Raynaud’s, collagen vascular disease, hypothyroid).  Skin turgor can tell a bit about endocrine pathologies as can pitting of the fingernail beds which can be a manifestation of thyroid problems.  Is there scarring or fibroses on the dominant hand’s knuckles of the teenager – scar from being repeatedly rubbed against her hard palate to induce vomiting.

A good physician is trained to use small observations as adjunctive information to a patient’s story – at times those observations are more reliable.  Over time, repetition shifts these observational skills to be more reflexive.  I certainly don’t diagnose strangers – small observations are clues and rarely conclusive by themselves.  But I can’t stop noticing those small and subtle differences in everyday life.  I’ll register it for a brief moment…then as reflexively as I notice these observations, I reflexively refocus on what’s important in front of me – often my family and friends.

Do MDs avoid diagnosing everyone (e.g., strangers on the street) when they are not working?