Last week I promised that I would expound upon the 25 bedside diagnostic techniques that Dr. Abraham Verghese, Stanford professor for the theory and practice of medicine, believes all physicians should know how to perform. Verghese believes, as I do, that “clinicians who are skilled at the bedside [or in the office] examination make better use of diagnostic tests and order fewer unnecessary tests.”
In an opening session of a series of workshops in which Verghese taught Stanford internal-medicine trainees (residents) these 25 essential techniques, he reportedly said: “My worst nightmare is a patient with a diagnosable, treatable disease that I missed because of sloppy technique.”
That should be one of your worst nightmares, too. With hands-on clinical practice and know-how increasingly being replaced by complete reliance on medicine-by-technology and sub-par clinical skills, it happens far too often.
In each of his workshops, Verghese focuses on a single diagnostic technique and what it can reveal to the skilled clinician. Enumerated below are his 25 techniques with his explanations either directly quoted or paraphrased by me. The original source is a special report published in “Stanford Medicine Magazine,” summer 2010.
1. Funduscopic exam: A physician uses an ophthalmoscope to examine the fundus, which consists of the retina, vessels, and nerves in the back of the eye, to help assess the “condition of blood vessels throughout the body, diagnose neurologic problems and provide clues to systemic diseases from heart valve infection to AIDS.”
2. Pupillary responses: Your pupils constrict and dilate to light and respond to distant and near vision. A physician can elicit papillary responses that indicate “trauma to the eye, and neurological disease and other conditions.”
3. Thyroid exam: Palpation of the neck to feel the thyroid gland can help to diagnose thyroid disease. “A nodule can indicate thyroid cancer. Without thorough training, people often feel too high on the neck,” says Verghese, “or place their fingers at an angle that precludes feeling a nodule.”
4. Neck veins: Jugular veins in the neck go directly to the heart and can indicate cardiovascular problems. “Seeing the neck veins and discerning their pulses takes a practiced eye, good patient positioning, good light and patience. Once it’s seen, the pulse level can be measured and abnormalities identified that can diagnose cardiac conditions such as tricuspid incompetence and complete heart block.”
5. Lung: “Percussing (tapping) on the chest and sounding out the lung’s boundaries [is] useful for detecting fluid or pneumonia, particularly in areas without access to radiology equipment and blood testing.” (I saw my father do this. It was like he could communicate in an unspoken language.)
6. Point of maximal impulse and parasternal heave: The point of maximal impulse (PMI) “is a dime-sized area of the chest, just left of the breast bone, where the beating of the heart can be felt. Heart and lung problems, such as hypertension or cardiomyopathy, create unique PMIs. The parasternal heave is an impulse originating in the heart or large vessels that can be felt with the heel of the hand resting on the left sternum. Though these are crude and simple maneuvers, they reveal much about the heart and can help physicians ask better questions of echocardiograms they order.”
7. Liver: Using percussion and other techniques, a physician can approximate liver size and feel the liver’s edge and surface, thus detecting nodules and masses. Verghese also teaches trainees how to feel for “tenderness in the gallbladder region and signs of gallbladder inflammation.”
8. Palpation, percussion of spleen: “The spleen is notoriously difficult to feel,” according to Verghese, “yet it is embarrassing to miss an enlarged spleen.” An enlarged spleen “is always always abnormal: It can be a sign of infection, tumor or liver disease.” Proper positioning of the patient and the examiner “is critical for success.”
9. Common gait abnormalities: “A person’s walk can indicate nervous system and musculoskeletal problems.” Gait abnormalities are common in patients with a stroke, Parkinson’s disease, peripheral neuropathy, and “multiple other conditions.”
10. Ankle jerk: “This is a natural reflex, a brisk forward movement of the foot, which occurs when a hammer strikes the Achilles tendon above the heel. An absent reflex might suggest nerve damage, but often a reflex is labeled absent only because of incorrect technique (in a bedridden patient in particular).” If an examiner can elicit this reflex, he or she probably can elicit the other reflexes.
11. Stigmata of liver disease: Signs of liver dysfunction are found outside of the abdomen. The so-called stigmata include spider angiomas (dilated capillaries) on the cheeks; parotid gland enlargement; diminished armpit hair; breast enlargement in men; islands of redness on palms, and “myriad other findings.”
12. Internal capsule stroke: One of the most common sites of stroke is an area deep in the brain called the internal capsule. When this stroke occurs, “a plethora of neurological signs . . . can be demonstrated, involving cranial nerves, muscles, sensation, reflexes and gait.” Through a series of maneuvers executed from head to foot, the physician can help to identify the location of a stroke.
13. Knee exam: “Well-validated means exist for establishing the presence of fluid in the knee and [for] testing for tears in a meniscus or ligament—each test involves a specific physical manipulation, which requires practice.”
14. Cardiac second sounds/splitting: “The healthy adult has two normal heart sounds (the familiar lub-dub), produced when heart valves close. The second sound is actually composed of two separate sounds produced by closure of the aortic valve and the pulmonary valve. Though they close together they become asynchronous after a deep breath. Many variations on this theme—exaggerated splitting or paradoxical splitting or fixed splitting—can speak to specific conditions such as bundle branch blocks or atrial septal defect, to name two.”
15. Involuntary movements: Verghese’s students learn to “identify and characterize the types of tremors as well as other involuntary movements, [which are] termed chorea, athetosis and several more.”
16. Hand: Many diseases show signs in the hand, from Down’s syndrome (an extra crease in the palm) to certain cancers. “The nail is affected by disorders ranging from cystic fibrosis to lung cancer. . . . [S]tudents learn to read the hand for everything from nerve disorders to specific finger deformities that in turn predict systemic disease.”
17. Tongue: “Visually inspecting the tongue for swelling, unusual color or texture can reveal signs of oral cancer, nutritional deficiencies or infection, such as HIV.”
18. Shoulder: The “shoulder joint is commonly affected by injury and aging. A series of observations and maneuvers can lead the clinician to strongly suspect a specific diagnosis, such as rotator cuff syndrome or even joint dislocation.”
19. Blood pressure assessment: “Accurate blood pressure measurement is dependent on correct use of the right-sized cuff in the right manner. In addition, the sounds heard when the cuff is deflated can indicate conditions such as fluid buildup around the heart.”
20. Cervical lymph node assessment: The size and presence of enlarged lymph nodes in the neck can indicate cancer as well as responses to therapy.
21. Ascites: Ascites, which is “the buildup of free fluid in the abdomen, around the organs,” is associated with liver disease, such as cirrhosis, but it also develops in heart failure and ovarian cancers. Verghese teaches a percussion technique to detect fluid.
22. Rectal exam: A digital exam of the rectum can help to detect cancers of the colon. It is also “a precious way to feel the prostate and other pelvic pathology.”
23. Evaluation of the scrotal mass: “A mass, or lump, in the testicle is a possible symptom of infectious disease, tumor or hernia.”
24. Cerebellar testing: Disease of the cerebellum, which is the area of the brain principally involved in motor control and coordination, “produces a whole list of abnormalities from speech to gait changes to abnormal reflexes.” Verghese teaches physicians to run patients through a list of tests and maneuvers, including “finger to nose,” “finger to finger,” “heel to shin,” and the like.
25. Bedside ultrasound: “Use of portable ultrasound at the bedside can identify fluid in the lung [and] free blood in the belly and determine if the patient is dehydrated or fluid-overloaded by studying a central vein.” Verghese believes that “an ultrasound might one day be among the contents of the white coat pocket.”
These 25 diagnostic techniques put the physical back in the physical exam and restore the concept of healing hands to doctors. I thank Dr. Verghese for developing and teaching them.