Table of Contents  
EDITORIAL
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 61-62

Wither “clinical evaluation”


Chief Editor – IJVES, Director – JIVAS, Bengaluru, Karnataka, India

Date of Web Publication6-Jun-2019

Correspondence Address:
Kalkunte R Suresh
Chief Editor – IJVES, Director – JIVAS, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_27_19

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How to cite this article:
Suresh KR. Wither “clinical evaluation”. Indian J Vasc Endovasc Surg 2019;6:61-2

How to cite this URL:
Suresh KR. Wither “clinical evaluation”. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Jun 25];6:61-2. Available from: http://www.indjvascsurg.org/text.asp?2019/6/2/61/259651



The other day, I walked into our outpatient department packed with people waiting to be seen. The fellows and my colleagues were scurrying around to clear the waiting patients as quickly as possible. One of the vascular fellows, responsible for initial evaluation of patients, called me to see a couple of patients. Their truncated and deficient presentation steered me to introspect on the state of the present-day clinical examination.

The first patient was presented as “a case (not a patient) of toe gangrene and only femoral pulse palpable. I am sending him for MR angiogram.” The second was a young female of 27 years with left fifth fingertip gangrene – “radial and ulnar pulses well felt. There is no clinical evidence of cervical rib. Should we send her for CTA?” – a very short presentation indeed. Forgotten were her history of hypertension and a marginally elevated random blood sugar in this very young patient!

Is this the fault of the teachers as we have accepted this “Paradigm shift in Mentoring”[1] and have failed to impart the importance of a good history and clinical examination to our trainees? Are we, the teachers, also responsible for pushing advanced technology first than clinical examination, and along with it, sacrifice the development of clinical judgment and acumen? It is indubitable that the rapid progress in medical scientific technology has immensely added to the diagnostic accuracy of patient's ailments. “Compared to the sharp images provided by ultrasonography, MRI/CT, angiography …. a patient's history is flabby, confused, subjective, and seemingly irrelevant. Furthermore, it takes a good deal of time to elicit a full history. According to some, technology has become a sufficient substitute for talking to the patient … indeed the doctor–patient relationship has been lost in the noise of high-tech medicine …. healing is best accomplished when the art (of clinical exam) and science are conjoined …” writes Dr. Bernard Lown, the famed cardiologist and Nobel Laureate in his fascinating book “The Lost Art of Healing.”[2] I would urge you to read this engrossing book, which is “… engaging memoirs of a distinguished physician who uses human interest stories to get across his message that healing a patient must once again be the focus of medicine” – a comment by a reviewer. The doctor–patient relationship of the days of yore is the basis for “healing” the patient if not “curing” the ailment. It would be apt to recall the counsel of Boston Physician Dr. Francis Peabody over 50 years ago, “The secret of the care of the patient is in caring for the patient.”

The necessity of clinical history has been known for 3000 years – as old as the history of medicine itself, as it is detailed in Hippocratic treatise. The first known document – “On the Interrogation of the Patient” – was written by Rufus of Ephesus,[3] who lived in Rome around 100 A.D. His statements hold remarkably true even today in the age of modern medicine – “It is important to ask questions of patients because with the help of these questions one will know more exactly some of the things that concern the disease and one will treat the disease better. One should start by interrogating the patient himself. One will learn just how sane or troubled the patient is and the degree of strength or weakness of the patient. One will obtain a certain notion of the disease process and of the body site affected ……. The physician will interrogate the patient first, and then question the relatives and friends, especially if he cannot learn from the patient himself.… It is important at the beginning to find out precisely when the disease process began.… You will ask about the rapidity and manifestations of the disease—whether the damaging phenomena developed rapidly, or on the contrary arrived and progressed slowly.… Ask if the disease has been present in the same patient previously.… I believe it is important to be informed of the nature of the disease in each individual patient, because we are not all formed in the same fashion, but we differ markedly from one another in many respects.”

Initial clinical assessment remains particularly relevant in vascular patients. At the end of the history and physical examination, a comprehensive diagnosis and treatment plan can be made for the patient before subjecting him/her to further testing, especially invasive diagnostic tests:

  1. Clinical diagnosis and its severity – e.g., Peripheral arterial disease (PAD) – functional (disabling or nondisabling claudication) or critical limb-threatening ischemia (CLTI)
  2. Anatomical level of the lesion – e.g., Aorta iliac occlusive disease/infrainguinal/infrapopliteal; disease
  3. Likely pathological cause – Atherosclerosis/TAO/vasculitis
  4. Can determine the need for further evaluation – e.g., If nondisabling claudication, physiological and other noninvasive testing might suffice. If clinically CLTI, it would dictate further advanced assessment
  5. The above would also dictate the need for further invasive revascularization strategies
  6. Risk factor assessment and further evaluation/therapy to control these factors.


It needs to be reiterated that none of the above need any “advanced” testing, which should be dictated by outcome of clinical assessment.

I would suggest the trainees peruse through JAMA's series on “Rational Clinical Examination.[4] Just a brief of some related to vascular diseases:

  1. Does the clinical examination predict lower extremity PAD?[5]


    • Context: Lower extremity PAD) is common and associated with significant increases in morbidity and mortality. Physicians typically depend on the clinical examination to identify patients who need further diagnostic testing
    • Conclusions: Clinical examination findings must be used in the context of the pretest probability because they are not independently sufficient to include or exclude a diagnosis of PAD with certainty. The PAD screening score using the handheld Doppler has the greatest diagnostic accuracy – Ed: clinical findings + handheld doppler have high accuracy in diagnosing PAD.


  2. Does this patient have deep vein thrombosis (DVT)?[6]


    • Context: Outpatients with suspected DVT have nonspecific signs and symptoms. Missed DVT diagnosis may result in fatal pulmonary embolism. Since many patients may have DVT, a selective and efficient diagnostic process is needed
    • Conclusions: Diagnostic accuracy for DVT improves when clinical probability is estimated before diagnostic tests. Patients with low clinical probability on the predictive rule have a prevalence of DVT of <5%. In low-probability patients with negative D-dimer results, diagnosis of DVT can be excluded without ultrasound; in patients with high clinical suspicion for DVT, results should not affect clinical decisions.


  3. Does this patient have pulmonary embolism?[7]


    • Context: Experienced clinicians' gestalt is useful in estimating the pretest probability for pulmonary embolism and is complementary to diagnostic testing, such as lung scanning. However, it is unclear whether recently developed clinical prediction rules, using explicit features of clinical examination, are comparable with clinicians' gestalt. If so, clinical prediction rules would be powerful tools because they could be used by less-experienced health-care professionals to simplify the diagnosis of pulmonary embolism. Recent studies have shown that the combination of a low pretest probability (using a clinical prediction rule) and a normal result of a D-dimer test reliably excludes pulmonary embolism without the need for further testing
    • Conclusions: The clinical gestalt of experienced clinicians and the clinical prediction rules used by physicians of varying experience have shown similar accuracy in discriminating among patients who have a low, moderate, or high pretest probability of pulmonary embolism. We advocate the use of a clinical prediction rule because it has shown to be accurate and can be used by less-experienced clinicians.


It needs to be stressed again that no advanced, remote diagnostic tool can replace a bedside diagnosis through thorough clinical examination. It is of paramount importance that the teachers impart, and students learn, the value of this “art” and then combine this with “science” of advanced diagnostic assessments for the good of the patients.

I leave you with these words of Dr. Drummond Reniie in the “foreword” of his textbook “The Rational Clinical Examination: Evidence-Based Clinical Diagnosis.”–

“By encouraging research into the history and physical examination, we wanted to restore respectability to a part of medicine that seemed to have been eroding as academic and financial reward went to those who most resembled scientists relying on expensive diagnostic tests and least behaved as physicians relating to patients.”[8]



 
  References Top

1.
Stephen E. Paradigm Shift in Mentoring. Indian J Vasc Endovasc Surg 2019;6:63-4.  Back to cited text no. 1
  [Full text]  
2.
The Lost Art of Healing – Bernard Lown. https://www.bookdepository.com/Lost-Art-Healing-Bernard-Lown/.  Back to cited text no. 2
    
3.
D'Ephèse R. De L'intérrogatoire des malades. In: Oeuvres de Rufus d'Ephèse. Paris: Imprimerie Nationale; 1879. p. 196-218.  Back to cited text no. 3
    
4.
5.
Khan NA, Rahim SA, Anand SS, Simel DL, Panju A. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA 2006;295:536-46.  Back to cited text no. 5
    
6.
Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does this patient have deep vein thrombosis? JAMA 2006;295:199-207.  Back to cited text no. 6
    
7.
Chunilal SD, Eikelboom JW, Attia J, Miniati M, Panju AA, Simel DL, et al. Does this patient have pulmonary embolism? JAMA 2003;290:2849-58.  Back to cited text no. 7
    
8.
Simel DL, Rennie D, Keitz SA, editors. The Rational Clinical Examination. New York: McGraw-Hill; 2009. p. 13.  Back to cited text no. 8
    




 

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