Preface

The more resources we have, the more complex they are, the greater are the demands upon our clinical skill. These resources are calls upon judgment and not substitutes for it. Do not, therefore, scorn clinical examination; learn it sufficiently to get from it all it holds, and gain in the confidence it merits.

—Sir Francis Walshe, 1952

Technical advances have made diagnoses quicker, safer, and more accurate. Sometimes it appears that careful history taking and examination are less important than knowing which test to order.

However, the technology is expensive and access is limited. As medical costs are increasingly scrutinized by the paying agencies, private or public, there will be limitations on both diagnostic investigations and hospital admissions.

For patients and doctors in smaller centers, limitations already exist. These conditions make a careful history and examination essential to the intelligent care of the sick and prerequisites for ordering tests. The practice of diagnostic medicine is not simply 'scene' recognition plus knowing where to point the technology. If it ever becomes this, a clerk—and eventually a machine— will be able to do it. Therefore, I suggest that you learn how to listen to and examine patients thoroughly and confidently. It is the most precious and durable skill you have; the more you use it, the better it becomes. It is unique.

One learns by doing the thing; for though you think you know it, you have no certainty until you try.

—Sophocles

In the examination of sick people a technique that elicits physical signs, and the ability to interpret those signs, are required.

Interpreting physical signs is one of the interesting parts of neurology. The process will not work if abnormal signs have been missed because of faulty technique, or if minor variations within the limits of normal are considered as firm abnormalities. Each year more students must be taught more subjects as the knowledge explosion continues. Only a small amount of time can be spent on the method of any physical examination. Therefore, learn a reliable technique quickly.

This book offers some anatomical and a smaller number of pathological possibilities that may explain a physical sign. It does not consist of a list of, for example, all the possible causes of an absent corneal reflex, and is not a small textbook of neurological diseases.

Teach and be taught is a ground rule that most of us will try to observe all of our professional lives. Every doctor and medical student owes a debt to patients, who are an essential part of the teaching situation. They allow us to teach 'on' them and around them, and they tolerate several history takings and physical examinations, usually for the benefit of someone else.

At all times one must treat patients with respect and kindness. When you enter the room, identify yourself and tell the patient why you are there. Do not persist with the history or examination past the point at which the patient is tired or uncooperative. Patients are most cooperative with students and doctors who are clean, neat, and polite.

When examining a patient, stand on the right side of the bed (or on the left if you are left-handed). After you have identified yourself, level the bed; that is, if the head or knee break is cranked up, flatten it. Then raise the bed as high as it will go. You can work better with the bed 30 inches from the floor.

Spend 60-75% of the time devoted to any one patient on history taking and the remainder on the physical examination. Have a system of examination and learn to follow it in the same way each time.

Do not be upset by the transient nature of some physical signs. You may see a patient with a slightly enlarged left pupil and explosively hyperactive tendon reflexes in the right arm and leg and a right extensor plantar response. Examination a short while later shows that the pupils and tendon reflexes are equal and both plantar responses are flexor. Both examinations were valid. Few physical signs of acute diseases of the nervous system are fixed. Papilledema is a notable exception. If it was present yesterday, it will be there today, tomorrow, and the day after. Almost all other signs can change hourly or daily.

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