Feb 20, 2011

General Appearance

A physical examination is one of two skills one has to master as a clerk. The first component of a physical examination is general appearance, where we evaluate and judge the patient for signs of chronic illness or disability. Its importance emphasized by Sir William Osler:
The art of the practice of medicine is to be learned only by experience, tis not an inheritance; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone can you become expert.
Judgemental as it may be, it does provides vital information for certain diseases. For example, a slowly healing ulcer may indicate poorly controlled diabetes; a patient who cannot recall what you asked a few moments ago may lead us to diagnose dementia.
So much for not generalizing or stereotyping, "general appearance" is actually quite close an epitome to it. What I learned this week was, despite what we were taught to judge patients by general appearance, we should withhold labeling them until we really get to know them better.
It was a busy Thursday evening when Mdm. TJ arrived in our ward. She suffered a mild heart attack and was transferred from a smaller hospital from Taitung because MacKay Hospital Taitung was full. Pending a coronary arteriogram to determine her severity, I quickly reviewed her information and important questions to ask during history taking - any dyspnea, chest pain, tightness, palpitations; what was she doing during the episode, risk factors etc. A few clicks and flip of old charts revealed the 68-year old having hypertension, diabetes, and end-stage renal disease. She smoked, drank, and chewed betel nut. In the world of medicine we usually refer these patients in a sinister way - often implying or projecting the idea that such patients are tough, does not care for their health, and difficult to manage.
When I walked into her single room, she was laying 75 degrees in sitting position looking utterly distressed. She was breathless and couldn't lie lower, and demanded sleeping pills because she usually takes them. She couldn't understand my questions and I couldn't understand her description either. We basically skimmed through our interview with help from her niece.
Sitted in front of the computer the following day, I wrote "an obese, chronic ill-looking, irritable woman older than actual age." I have no intent of discrimination, but the way I expressed the sentence made my patient sound pitiful, plagued with disease and riddled with problems.
She was to prove my first impression wrong with every subsequent visit. I see different sets of people taking care of her every day over the week, and as she gets better she talked to me about switching to a 4-bedded ward.
"But it's much noisier there. Are you sure you'll be able to sleep well?" I asked.
"I know. But I don't want to burden my children to pay for my medical fees."
"Oh, that's my mother! Always trying to think on our behalf instead of hers!" Her daughter, standing beside her, exclaimed.
Later that day her daughter told me in private that she never took a penny from her children. She lived on her own savings and the little income she made with her fruits and vegetables.
Meanwhile, worried about her problem with diabetes I asked her if she had had any diet consultation before and whether she took her drugs regularly (usually they don't). I was completely taken aback when she told me how much calorie is in a tofu block and she can only eat half every day.
"You should also be careful about tea as well because you have chronic renal failure," I said.
"Of course, I only drink water nowadays."
I couldn't hide surprise showing up on my face.
A few days later she recovered into a cheerful, bubbly woman who'd smile when we visited her every day. I would try my Taiwanese Hokkien with her and she would laugh at my futile scramble of vocabulary. Her initial "general appearance" was totally off what she really was.
Stealing some time off lunch break I hurried into her room before discharge. She was happily eating her last hospital meal (nothing happy about hospital meals by the way), and thanked us for our care. I wished her good health and learned an important lesson that week.