It was a breezy spring morning. I stole a moment to look through the clinic windows, then admonished myself to work more efficiently. Patients occupied each of the exam rooms and the waiting area was beginning to fill with women and children. The medical student approached and said hesitantly: "Dr. Castro, one of the patients seems sort of confused. When I try to get a history from her she just shakes her head."
I looked over the patient's chart. She was diabetic, pregnant, on insulin. Her vital signs were normal and her glucose control seemed optimal, judging from the blood sugars recorded in her log. "Perhaps," I said smugly, "you are not fluent enough in Spanish. I'm sure she will have no trouble understanding me."
Confidently, I entered the room. "Hola, senora, como se siente hoy?" The patient smiled at me and shook her head. "Tiene algunas problemas?" She still just smiled. "Esta confundida?" I asked, confused myself at that point. She shook her head again. Disappointed, I said to the student: "We need a translator -- I can't communicate with her either."
I suggested that the student bring the patient to the ultrasound room while we waited for the translator so we could determine whether the diabetes had caused any fetal growth abnormalities.
Then I looked at the patient again and asked the student, "What was her fundal height?" The fundal height measurement is the size of the uterus in centimeters from the pubic bone to the top (or fundus) of the uterus. It is one of the most basic components of the physical exam of a pregnant woman and should be performed by the physician or midwife at every prenatal visit after the first trimester. When done in conjunction with palpation of a pregnant woman's abdomen, it provides information on fetal growth, size and position.
I admit that I often skipped this exam if I were going to do an ultrasound. Why take the time to measure the fundal height when I could obtain the needed information more accurately with the ultrasound? But that day I was with a student. To determine if he was doing the exam correctly, I had to repeat it. With the paper tape measure in one hand, I bent over the patient and placed my other hand on her abdomen to feel the uterine fundus. As soon as my fingers touched her cool, damp skin I experienced an immediate shock of recognition. The woman was hypoglycemic -- that's why she was confused. We had to quickly raise her blood sugar if we were to prevent a hypoglycemic seizure or loss of consciousness.
Rapidly we instituted corrective measures and obtained serial blood sugar measurements. Once they rose to the normal range, the patient no longer exhibited any signs of confusion and there was no communication difficulty.
An ultrasound revealed that the fetus was growing normally. We adjusted her insulin dose, reviewed her diet and counseled the patient and her family on the signs and symptoms of hypoglycemia as well as the importance of always having some hard candy or sugar tablets available should her blood sugar start to drop. We also instructed them on the use of glucagon injections should she have an episode of severe hypoglycemia at home.
Later that evening, I phoned to review her blood sugar control. She assured me that she was doing fine and that her blood sugar was normal.
The iconic image of a healer who is able to cure the sick by the "laying on of hands" transcends time, place, culture and religion. Today, "the healing power of touch" is the promise of many a practitioner of alternative medicine, while the conscientious practice of that more pedestrian form of laying on of hands -- the physical exam -- is declining. Traditionally, medical students are drilled on four points regarding the exam: inspection (look at the patient), auscultation (listen to the heart, blood vessels, lungs and abdomen with the stethoscope), palpation (feel for the presence of masses or abnormalities of temperature or pulse), and percussion (use a tapping maneuver to detect the buildup of fluid, gas or enlargement of abdominal organs).
Training and practice are needed to look at a lesion and determine if it is likely to be cancerous, to detect pneumonia via percussion, to auscultate the tell-tale signs of heart failure or to correctly interpret the findings on a pelvic exam. The combination of a careful history and a physical exam often can lead to the correct diagnosis without any ancillary diagnostic studies. In any case, they'll narrow the number of likely diagnoses so that only the most appropriate tests are ordered and their results interpreted correctly.
At least, this is what we teach.
In practice, confronted with increasing pressure to provide care for more patients in less time plus the wealth of diagnostic studies available, we often quickly obtain a focused history from a patient and then formulate a diagnosis. It can seem that we have little to gain by spending the extra time it takes to do a careful physical exam. We might perform it in a cursory manner, delegate it or even, perhaps, bypass it, relying instead on laboratory tests and imaging studies to confirm or refute our diagnostic impression. These can be quickly ordered and their results even come highlighted as "normal" or "abnormal." Papers in distinguished journals emphasize these latest technologies, and physicians don't want to appear outdated. Patients themselves sometimes demand such tests before I've had a chance to perform an exam.
We sometimes forget that even in cases in which an exam may appear to have limited diagnostic value, it can facilitate a sense of trust and caring between physician and patient. Consider a conversation I had with a frustrated elderly woman who was complaining of diffuse back and rib pain and had just returned from a doctor's visit.
"Did he examine you?" I asked.
"No, he didn't touch me," she said. "He barely looked at me." The doctor simply asked her a few questions, typed in his computer and sent her for an X-ray.
A radiologic study probably was needed, but her physician missed the opportunity to look more closely, reassess and provide a human touch.
As for me, I need to thank the diabetic patient who came to my clinic that spring morning. Her visit resulted in one of those small but important epiphanies that physicians occasionally experience in the course of seeing patients.
If anyone had told me I would diagnose hypoglycemia by performing a fundal height measurement, I'd have laughed. But this woman's visit taught me once more the value of the physical exam -- specifically, the importance of palpation -- in making the correct diagnosis. I recognized that simply as physicians examining patients, we do occasionally have the healing power of touch. I hope we never lose it.
Castro is professor and chair of obstetrics-gynecology at Western University of Health Sciences in Pomona.