What were you doing in April? Well I was having a birthday, holding out to complete six months of breastfeeding in order to receive a certificate (never got this – still pretty miffed, fyi) and trying to do some more of this medical blogging business that seemed like such a good idea one night when I’d had a few beers and sang John Grant’s ‘GMF’ thirteen times in a row.
In that last blog, I wrote down this piece of information: ‘80% of diagnoses are made from the history alone’. Remember that? It’s okay, me neither really, but let’s pretend we do in order to carry on unabated with the next enthralling chapter of this series. Given, then, that most of our information about a patient comes from merely having a good old chinwag, how else can your medical professionals track down clues to diagnose you? I will, at some stage – Christmas 2017, I imagine – discuss investigations that are done, because they are a vital component of diagnosis and monitoring, but before I get there let’s chat about EXAMINATIONS.
Chances are you might not have undergone many of these. When you visit your GP, perhaps they’ve taken your blood pressure, or listened to your chest if you’ve gone in with an infection. Most women will have had smear tests done, the results of which get sent off for INVESTIGATION (golly, this is all tying together beautifully), but we don’t often get a full work-up. It tends to happen more in hospitals, where problems may be more acute and generally follows the point where a person is admitted and has had their history taken. The point of examination is to look for signs, a person can tell you their history, but their body will demonstrate these physical clues that are manifestations of the activity inside our bodies. Clever eh?
Examination follows a nice little order. Medicine loves routine, and following the same one in the same situation is also a very handy way of making sure bits don’t get left out. So, when doctors examine someone we Inspect (have a good nose), Palpate (have a feel of things), Percuss (tap things to see how they sound) and Auscultate (have a listen with our prized stethoscopes). My stethoscope is orange and you can have that personal fact for nothing because, my friends, sharing is caring and I’m a very caring person.
If you went into hospital with dizziness and head pain, you would undergo a very different examination to the one you’d be given if you were, say, throwing up blood, so for the purposes of this post, let’s pretend you’re going in with acute stomach pains. Whoever was seeing you would want to perform a full gastrointestinal exam, so I’ll talk about that here, with digressions if I think it’s interesting. We’ll get along better if you take the word ‘interesting’ in it’s very loosest interpretation here.
SO, after the initial hand-washing, introductions, explanation of procedure and gaining informed consent (i.e. you know exactly what will be happening to you and you agree to it), the doctor will start having a good old nose at you, not even close up. They might have been doing this from the moment you walked / were carried in / they came to your bed, because there’s a lot of information that can be collected by simply being observant. You can usually tell if someone is in pain, if their breathing is normal, if they have any medical appliances by the bed such as walking aids or oxygen, or maybe some of their medications are on the side.
First port of call for a very detailed inspection though is the hands. Although they probably seem fairly irrelevant when you’re clutching at your belly in agony, our hands show a lot of signs relevant not only to our gastrointestinal system, but our heart and lungs as well. Impressive eh? Glad I’ve got your attention actually, because I might be about to list some things and lists are always hard-going. Just getting Miss Marple-ish about the fingernails alone can reveal the following signs:
- Koilonychia (where your nails become more concave and spoon-shaped), which may point to iron-deficiency anaemia
- Leukonychia (whitening of the nails) which may be due to injury (those small white dots you get from time to time) or a sign of low albumin levels or liver problems
- Nail clubbing (take the same finger on both hands, place nail against each other, normally there is a little diamond-shaped space at the nail bed between the two – in clubbing, this is absent). Nail clubbing is most commonly an indicator for heart and lung conditions, but can also occur in gastro stuff like Crohn’s or cirrhosis
- Tobacco staining – if someone says they’ve never smoked but their two ‘smoking fingers’ are stained, this is important information
- Palmar erythema (reddening of the palms around the thumb area) which can be an indicator of many conditions such as liver disease, although it often occurs in pregnancy or may be part of a skin condition like eczema.
- Dupuytren’s contracture (where the fingers, particularly small and ring finger, curl in towards the palm, affecting function) which may ‘just happen’ but may be an indicator of liver cirrhosis. It also tends to affect men over forty with Viking ancestry. Little free fact for you there.
After this the patient is asked to hold out their hands straight in front of them, this checks for tremor, and then to extend the wrists so the fingers point towards the ceiling, which may reveal asterixis, also known as a liver flap, where the hands jerk in this position and which may be an indicator of liver problems or even carbon dioxide toxicity. At this point it’s good to take the pulse at the wrist (your radial pulse) as that’s always good information to have.
So there we go. That’s part one of how to do a gastrointestinal exam, and I haven’t got beyond the arm yet but my baby is waking up from her nap, the cats are fighting in the chimney and my personal hygiene requires some rather thorough and urgent attention. You’ve either switched off or are furiously checking your hands for signs that you about to shuffle off this mortal coil in an imminent fashion (spoiler: you are probably not). I hope you found this vaguely interesting but in the highly unlikely event that you did not, may I warn you that there will only be more of these to come and refer you instead to Google Images and the keywords ‘cats in bikinis’. You’re welcome.