The Invisible Exam: Introducing the Amazing Ocular
Scantron!
by Ginger Savely, DNP
Telephone medicine is becoming increasingly popular as busy patients and doctors try to fit appointments into their overly-scheduled lives. Patients have asked me why they need to come in to the office for follow-up visits when we can talk just as easily by phone. In fact I do occasionally conduct phone visits with patients who live so far from my office that regular in-person visits would present a financial and physical burden. Furthermore, when patients do come in to see me, they often wonder why it was necessary since I am simply speaking with them face to face rather than performing a physical exam. Why don't I do a physical exam at every office visit? And since I don't, why can't all the visits be by phone?
There are four parts to the classic physical exam - inspection, auscultation (listening to a body part with a stethoscope), palpation (feeling with the hands) and percussion (a tapping skill that is becoming a lost art thanks to the advent of the sonogram). Inspection is the most important diagnostic skill to be mastered in both Eastern and Western medicine. A heightened power of observation is not just something a detective must master - the diagnostician must excel at this as well.
What you probably don't realize is that your health care provider does a fairly extensive inspection of many of your body systems without you even knowing it. There is a remarkable amount of data gathered as you, the unsuspecting patient, sit across from your health care provider talking and listening.
Here comes the part about the amazing ocular scantron! You thought you were going to read about a new testing device, didn't you? A magical way to examine a patient over the phone or the internet? Or, perhaps a diagnostic wand much like Dr. McCoy used on StarTrek to instantly diagnose his fellow Starfleeters by passing it over their bodies?
Actually, it's far less high tech than that. Without you knowing it, your provider is scanning dozens of data points with his eyes - thus, the "ocular" scantron! The only reason you are not told there is an exam in progress is that your health care provider is multi-tasking in order to save time and allow as much to transpire during your office visit as possible. Let's take a look at some of the important information I gather about my tick-borne disease patients without them even knowing it. Let the scanning begin!
When I call the patient in from the waiting room, I observe the agility with which he arises from his chair. I note his countenance - does he look in pain, depressed, serious, agitated, nervous, happy, relieved to see me? How is his color - pale, sallow, yellowish, flushed? Are his temples sunken? Is there a "glassy" appearance, redness or yellow tint to the eyes?
How is he dressed? Is he over or underdressed for the temperature of the room? Does he appear dirty or unkept, suggesting problems with self care? Does he smell of body odor, alcohol, cigarette smoke? I watch his gait as he comes down the hall. Is there a limp, an imbalance, a shuffle or other unusual gait? Is he using a cane for balance?
As he sits, does he slouch or sit up straight? Is he fidgety or relaxed? I look at the neck to see if there is an obvious enlargement of the thyroid or the lymph nodes. I notice whether the hair looks oily, dry, sparse, or unkempt. I can now see the hand and nails and note if there are swollen finger joints, atrophy, bent fingers, or pitting or ridges on the nails.
I review the vital signs that were taken by my office assistant. Is there fever or below-normal body temperature? Is the pulse rapid? Is the blood pressure abnormally high or low? Has there been a change in weight - either a loss or a gain?
There are 12 cranial nerves (CNs) and I do a cursory check on all but one of these (CN 1, smell) while observing the patient as I speak with him. As I listen to the patient talk, I note the ease with which he expresses himself. Are there word-finding problems? Articulation irregularities (CN 5, 7, 10, 12)? Is there a rapid stream-of-consciousness flow of ideas or an organized, focused presentation of concerns? Is the voice newly hoarse or nasal (CN 9 and 10)? Is there even a slight palsy or droop on either side of the face or an uneven smile (CN 7)? Does one eyebrow appear lower than the other or does either eyelid droop (ptosis)(CN 3)?
Are the eyes tracking properly as they move around the room? Do they move in symmetry? Are the pupil sizes asymmetric or abnormally small or large? Is the patient squinting or having difficulty seeing (CN 2, 3, 4 and 6)? Is he having a problem hearing my questions (CN 8)? As he speaks, is he able to turn his head from side to side (CN 11)?
In their training, clinicians learn the importance of "pertinent negatives" which are absent findings that are significant to note. For example, if a clinician is evaluating a patient for nausea and vomiting he would want to note the absence of signs of dehydration such as dry lips or flushed skin. However, if he is evaluating the same patient for a sprained ankle, these negative findings would not be relevant. So, often the scanning involves noting what is not there, as your health care provider assimilates assessment data. Every data point, whether present or absent, provides a diagnostic clue. Let the scanning continue….
Are there involuntary movements (myoclonus) in any part of the body? Do movement of the arms and hands during conversation seem fluid and purposeful rather than jerky and random? Is the breathing noisy, rapid, or labored or is it smooth and soft? Does the patient cough during the visit?
Is there puffiness in the face, hands, legs or ankles and if so is it unilateral or bilateral? Does the skin and hair look dry and flaky or oily? Are there sores or rashes on the uncovered area of the skin?
There are probably dozens more subtle signs that your health care provider picks up as he talks with you. So, the next time you have an office visit and think you are not being examined, think again! Hopefully you will not be self-conscious knowing you are under the scrutiny of the amazing ocular scantron!
