A forgotten skill in the present era: Clinical examination

Dear Editor, This is to highlight the importance of forgotten clinical skills in the current era. Proper history-taking and adequate clinical examination are one of the most important skills for any medical practitioner. Of late, this medical skill is replaced by laboratory investigations and radiological investigations. This leads to a lot of medical errors in the diagnosis and a battery of unnecessary investigations. This leads to a delay in the necessary treatment at the appropriate time.[1] Proper history-taking and clinical examination will reduce the financial cost by avoiding unnecessary investigations. Not performing or doing a poor physical examination is a threat to patient safety as the probability of diagnostic errors increases. This case is a classic example for highlighting the importance of history taking and proper clinical examination.[2] A 52-year-old male presented with abdominal discomfort for 2-month duration. There was a history of loss of appetite and loss of weight for 2-month duration. There was no history of passing black-colored stool or blood in the stool. There was no history of passing high-colored urine or yellowish discoloration of the eyes. He was not a known case of diabetes, hypertension, tuberculosis, and coronary artery disease. He was not a smoker or alcoholic. He went to multiple hospitals and was diagnosed with acid peptic disorder. He was prescribed a proton-pump inhibitor and antacids. Later, he went to medical college for persisting symptoms. There he underwent an upper gastrointestinal endoscopy. Endoscopy showed pangastritis and a biopsy was taken. Biopsy shows chronic nonspecific gastritis. He was given the course of proton-pump inhibitor again. In spite proton-pump inhibitor for more than 1 month, his symptoms persist. He later reached us for persisting symptoms. After obtaining a medical history, an abdominal clinical examination shows a huge hepatomegaly. Later, he underwent computed tomography which showed a mass in the fundus of the gallbladder infiltrating on segments 4B and 5 with hepatomegaly of 22 cm. Computed tomography (CT) also shows periportal, portocaval, paraaortic, aortocaval, retrocaval, and bilateral common iliac lymph node. CT is suggestive of gallbladder carcinoma with liver metastasis. Positron emission tomography-CT showed carcinoma gallbladder (T3) with extensive hepatic metastases. Multiple regional and nonregional lymph node metastases (N2) with extensive and peritoneal metastasis (M1) were seen. He was given palliative chemotherapy gemcitabine with cisplatin. Despite chemotherapy, the patient succumbed to death after 1 month. The letter to the editor brings up a critical issue in today's time, which is especially true for diagnosing malignancy. His multiple visits to physicians have overlooked the history of loss of weight and missed per abdominal palpation of hepatomegaly to warrant radiological examination by either a CT scan or ultrasonography of the abdomen. Apart from making a proper diagnosis, clinical examination creates a bond and trust between the patient and the health-care provider. Proper physical examination has a vital role in primary health care compared to secondary, tertiary, and quaternary health care due to the availability of radiological investigations. This helps the primary physician make a differential diagnosis and refer to a higher center at the early stage of the disease.[3] Sometimes, radiological investigations and laboratory investigations fail to provide a clue about the current disease and disease progress. In those cases, proper clinical examination with correlations of laboratory investigations helps for proper diagnosis.[4] For example, a female with a proper menstrual history and examination will identify a case of ectopic pregnancy and ovarian torsion. This will avoid catastrophic complications such as rupture and hemorrhage. Proper inguinal examination in males and females will diagnose a case of obstructed femoral hernia and will avoid catastrophic complications such as intestinal obstruction, gangrene, and perforation. Inadequate history taking and examination and relying purely on laboratory and radiological investigations are not only threats to the patient's life but also lead to potential medicolegal litigations.[5] Hence, for any health-care provider whether in a primary, secondary, tertiary, or quaternary setup, it is always mandatory to do a proper clinical examination before ordering the battery of unnecessary investigations. This not only reduces medical errors but also increases the patient's confidence and reduces the financial burdens for the patient. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.