Clinical Manifestations
“The four points of a medical student’s compass are: Inspection, Palpation, Percussion, and Auscultation.”
– Sir William Osler –
The Card System:
1. The Definition
2. Epidemiology
3. Aetiology
4. Biological Behaviour
5. Clinical Manifestations
6. Investigations
7. Management
8. Some Basic Examples
9. The Riddle of the Sphinx
10. The Master Word
Louis Pasteur said that in the field of observation, chance favours only the prepared mind. Indeed, a prepared mind is essential for good diagnostic skills, and the system presented on this card is among the most useful of aids that you will meet in this book. Diligent application of this system will make you a better clinician, and prevent you from missing many important clues.
Symptoms are the narratives of what a patient feels. They may be local or systemic – an upper respiratory tract infection, for example, will produce specific ‘local’ complaints such as a sore throat or cough, but also non-specific ‘systemic’ features relating to the activation of the patient’s immune system, such as fever or malaise. The metastatic heading proves useful for tumours and infections, which may both produce symptoms by spreading to distant sites. The heading is also useful in a looser, more catholic sense, to discuss the symptoms of complications you met in the biological behaviour section. Alternatively, you may choose to simply use the heading complications for some topics. The ‘endocrine’ heading is useful not only in specifically endocrine conditions, but may also be used loosely to discuss metabolic changes that occur in an illness, or for paraneoplastic conditions. Remember that because they are patient narratives, symptoms are best written in layperson’s terms.
Signs relate what is found on clinical examination. There are many excellent texts discussing systems for elucidating signs in clinical medicine, and such systems should be learnt and practised until second nature. The clinical manifestations card simply lists Osler’s fundamental ‘compass points’ of signs: inspection, palpation, percussion and auscultation. Meditation is another addition of Osler’s, to remind us always to pause, think and reflect at the bedside after the examination. You may use headings from other systems to discuss different disorders, such as tone, power and reflexes in a card on a neurological topic. Remember that signs may also occur locally, systemically, or in ‘metastatic’ and ‘endocrine’ ways.
Each case has its lesson – a lesson that may be, but is not always, learnt, for clinical wisdom is not the equivalent of experience. One who has seen 500 cases of pneumonia may not have the understanding of the disease which comes with an intelligent study of a score of cases.
Sherlock Holmes and the Legacy of Dr Joseph Bell
Sir Arthur Conan Doyle graduated as a doctor from Edinburgh University in 1885. He practiced for six years before becoming a full-time author. He based his most famous character, the detective Sherlock Holmes, largely on Dr Joseph Bell (1837-1911), surgeon and teacher at Edinburgh University.
Bell (pictured) had such outstanding observational skills that it is said that he could tell patients their habits, occupations, nationality, and even their names just by looking at them, and rarely, if ever, made a mistake. “The student must be taught to observe,” he said, “From close observation and deduction, you can make a correct diagnosis of any and every case. However, never neglect to ratify your deductions”.Bell was a dramatic man, and enjoyed terrorising his students. “What is the matter with this man, Sir?” he would inquire, “come down, sir and look at him! No! You mustn’t touch him. Use your eyes sir! Use your ears, use your brain, your bump of perception, and use your powers of deduction.” On one occasion, a student replied, “Hip-joint disease, Sir!”. Bell retorted: “Hip nothing! The man’s limp is not from his hip, but from his foot, or rather from his feet. Were you to observe closely, you would see that there are slits, cut by a knife, in those parts of the shoes where the pressure of the shoe is greatest against the foot. The man is a sufferer from corns, gentlemen… [though] his trouble is of a much more serious nature. This is a case of chronic alcoholism, gentlemen. The rubicund nose, the puffed, bloated face, the bloodshot eyes, the tremulous hands and twitching face muscles, with the quick, pulsating temporal arteries, all show this. These deductions, gentlemen, must, however, be confirmed by absolute and concrete evidence. In this instance my diagnosis is confirmed by the fact of my seeing the neck of a whiskey-bottle protruding from the patient’s right-hand coat pocket.”
On another occasion he stated “Gentlemen, a fisherman! You will notice that, though this is a very hot summer’s day, the patient is wearing top-boots. When he sat on the chair they were plainly visible. No one but a sailor would wear top-boots at this season of the year. The shade of tan on his face shows him to be a coast-sailor and not a deep-sea-sailor – a sailor who makes foreign lands. His tan is that produced by one climate, a ‘local tan’ so to speak. A knife scabbard shows beneath his coat, the kind used by fishermen in this part of the world. He is concealing a quid of tobacco in the furthest corner of his mouth and manages it very adroitly indeed. The summary of these deductions shows that this man is a fisherman. Further, to prove the correctness of these deductions, I notice several fish-scales adhering to his clothes and hands, while the odour of fish announced his arrival in a most marked and striking manner.”
It is easy to see how the Sherlock Homes character grew out of the larger-than-life Bell. Here another statement from the detective world of Sherlock Holmes that applies well to medical thought:
“Sherlock Holmes closed his eyes and placed his elbows upon the arms of his chair, with his finger-tips together. ‘The ideal reasoner,’ he remarked, ‘would, when he had once been shown a single fact in all its bearings, deduce from it not only all the chain of events which led up to it but also all the results which would follow from it…”
As you may expect, Joseph Bell greatly enjoyed the Sherlock Holmes stories.
In addition to being a brilliant doctor, Bell was also an amateur poet, a sportsman and a bird-watcher.