Wednesday, September 5, 2012


    When I was in medical school , I was taught the basics of medicine .We were very young and were taught proper way of taking history and proper way of examining patients . We had to do this in every case even if the diagnosis is obvious. It may be due to lack of all the tests that are available today , like CT scan, PET scan , echo cardiogram or stress tests or many other tests , but we had to be sharp in our history taking and our examination skills. Thank God that I have not left this habit , now that we have every patient getting all these tests .The case that I am going to describe is one that is illustrative of this fact .
     I was called in for a consult in Intensive care Unit . Patient was a 70 years old patient , who was admitted to hospital , with multiple medical problems . She had stroke and was admitted to hospital about 6months ago and needed to be on respirator. As she could not be weaned weaned off the respirator, she needed tracheostomy. She could not eat , so had feeding tube put in . She also had urinary catheter and had a line for intravenous medicines . She was in a nursing home . She had a routine blood test done and it showed renal function worsening. On the day of admission her blood pressure dropped , and so she was sent to hospital ER and then was admitted to Intensive care unit .
     When I saw her it was 6-30 pm . and the admitting doctor had seen her . She was also seen by kidney specialist and infectious disease specialist . They had ordered no. of tests , Intravenous fluid, and no. of antibiotics. Their notes had differential diagnosis and even a mention that  if  she did not improve, she would need dialysis. I saw her , spoke to the nurse and examined her . She was on respirator with history of stroke , so was unable to talk or communicate much.
     The CT scan of chest and abdomen were ordered .I saw her and EXAMINED her . I told the nurse that she needed to change the urinary catheter .She told me that the catheter was working 'fine ' as there was urine coming out .I told her to change it anyway as it was blocked and if it was changed , her kidney function would be most likely be normal by AM. I left ICU .
      By next morning , when I saw her she had put out 3700ml of urine in 12 hrs. and her kidney function was almost normal . Her blood pressure was normal and she was 'fine'.
    When I was in medical school ,we had to do 4 phase examination . ,Inspection , Palpation , percussion and auscultation . It did not matter if patient had obvious hernia or we were doing chest examination .If we did not follow this sequence , and  that to a point of being seen by our teacher , he would hit on our hand . We must first 'inspect' then 'palpate ' then the last two . In the patient , that I mentioned , when I felt her abdomen , I felt huge , distended bladder. (All other doctors had written that there was feeding tube and there was no mention of any other findings and definitely not that of distended bladder. )She did not have 'sepsis' nor did she need any dialysis. All that she needed was simple change of her catheter.. So in the age of all the scans , and other tests that we have , we still need basics of examining patient.

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