General Observation

You, as a medical student, will be seeing a patient after an initial assessment by another physician. He would have set into motion certain actions which are clues to the patient's problem. Medicine is an art. Learn to be like a detective in solving medical problems. Be attentive. Observe, smell, listen and feel for clues. Let me present you with a few examples:

• Patient in isolation : Most likely he has a suspected contagious illness like tuberculosis.
• Patient is in reverse isolation : The patient is being protected from you. Patient is immuno-incompetent and is likely to get infected easily.
• Patient receiving 1/2 liter of 02 by nasal cannula : In general, patients with COPD receive low FIO2.
• Foul smell to his breath : Patient probably has anaerobic infection. If the gums are healthy we should suspect lung abscess or bronchiectasis.
• Has a hoarse voice : May have a lesion in larynx or vocal cord paralysis.
• Has a bovine cough : This implies that he has ineffective cough and suggests vocal cord paralysis. In pulmonary cases, this generally would mean left vocal cord paralysis. The lesion is most likely in the aorto-pulmonary window.
• Appears cachectic: We are looking for diseases that are characterized by weight loss eg; cancer, TB, etc. Patients with sarcoidosis usually appear healthy.
• Is massively obese : Patient could have respiratory center problems, eg, Sleep apnoea syndrome.

Example:

Patient appeared cachectic. Both empyema and malignancy can lead to significant weight loss. You would have taken the history before starting physical exam. Suppose if I tell you that the patient is 60 years old male, 2 pack a day smoker for 40 years , comes in complaining of shortness of breath, weight loss of 30 lbs over 1 year and increasing cough with occasional tinge of blood. You obviously will come to the conclusion, most likely that he has malignancy. Confirmation of your clinical suspicion would require getting a CXR and pleural tap. Thus physical exam can help you determine the pathological process. However many etiologies can give the same pathological process. History will help you narrow down the considerations. Then you do investigations to confirm your clinical suspicion.