Watchfullness !

I watched this migrant bird beside a pool of water in a waterbody, staying vigilant for it to spot a fish. Its readiness and alertness was explicit in its body posture!

Yesterday, I came across a family who visited me a few times for consultation recently. During the first visit when I usually do a detailed clinical examination, I search for neuro-cutaneous markers. I ask the parents for any pigmentary changes they noticed on the skin of their child and complete the examination by looking for them. One child who has recurrent convulsions who came for follow up yesterday needed a review of the diagnosis and audit of the treatment. It was during this exercise that I went through with a detailed inspection of the skin. To my surprise tI found some neuro-cutaneous markers.  My colleague reminded me that I asked the parents during the previous visits about any colour change on the skin, but did not strip him to examine. With other colleagues in the room I might have avoided examining a pre-adolescent boy in public and went by the word of parents.

It was a costly omission. This finding of neurocutsneous market gives a different diagnosis, and a revised approach to understand his recurrent seizures.

I have been generally vigilant in clinical examination so much so my colleagues wondered whether all the details I look for everyone are necessary at all! Yesterday's example was a lesson for all of us. There is no short cut or assumption in clinical examination- everything has to be factual, observation based and evidence supported. 

It is now forty-five years since I have been in clinical practice, out of which thirty five years have been in the specialty of developmental neurology. I have avoided being interrupted by telephone calls, visitors or any other interruption when I am with a child and family during a consultation. That is one way of staying focussed. What is even more important is to think through the differential diagnosis while history is being taken and the clinical examination is being conducted. There is a need to cross check at the end of the clinical examination, when there is an ambiguity of diagnosis. 

The bird in the picture is a symbol of vigilance !

I take home the message: Stay vigilant during a clinical examination. 

The other lesson: repeat the clinical examination when in doubt 

A third lesson: refer to a colleague with a request to examine and offer any new thoughts. When this child was seen by a dermatologist yesterday after our clinical suspicion of a dermatological condition being a probable cause for the intractable seizure, the dermatologist concurred with the suspicion and proposed another dermatological condition different from what we thought of. We are looking into that now with more investigation.

Some of us in the practice of clinical medicine need to be willing to go that extra mile to rely on our experience as well as follow the protocol and process of clinical examination without taking any short cut! Sometimes it calls for doing al these ourselves rather than only depend on our younger colleagues. It reinforces and demonstrates the primacy of clinical examination to our younger colleagues.  

M.C.Mathew(text and photo)