A good clinical examination clinched the diagnosis .

Years back while working as the senior resident in Medicine, a young business man Mr Raj  (name changed) was admitted for evaluation of swelling of feet of 3 weeks duration.

On evaluation he was found to be losing proteins in urine (Nephrotic range proteinuria)

 A kidney biopsy was planned by the admitting dept for this patient to know the cause of protein loss through kidneys.

Sadly on the day of kidney biopsy Mr Raj  developed high grade fever and the procedure was cancelled.

The treating team send all  investigations required to know the cause of fever.

But there was not a single  clue from any of the  investigation sent.

Mr Raj continued to drench in fever .

 Finally they send a reference to internal medicine for advice.

I went along with my consultant to see the patient.

” Hello  ji” my consultant greeted Mr Raj in a  sweet tune   with a  smiling face.

Then he  started the  clinical examination .

While he was examining I, as senior resident, started  scrutinising the case record of the patient near the foot end of the bed .

I must confess while turning the pages of the file and making note of investigations carried out by the treating unit, strange thoughts started racing in my mind.

 How  we gone a make the treating team wiser?

They had sent all necessary investigations required  in the evaluation of fever.

 I don’t feel  out of place to mention that ranging from infection to auto immunity,  the diagnosis of fever at times becomes very challenging.

 Coming back to the patient, my consultant  finished the clinical examination and called me.

“Ibrahim, come here and he  guided my hand to the neck of the patient.

Do you feel something here, yes, a little here, yes, yes…..

” Yes sir, there is a small lymph node” I replied.

“Ibrahim, ask them to take it out” said the consultant.

 The work up used to be very swift in this hospital.

The lymph node was taken out and sent for histopathology.

Two days  later the reports were ready in the wee hours.

The lymph node biopsy was suggestive of  Lymphoma, a great surprise.

 Mr Raj was started on chemotherapy.

With this treatment his fever settled and Kidney biopsy was cancelled  as it was not required.

The patients kidneys were losing proteins due to Lymphoma and not due to kidney disease per se.

Thus proteinuria had been tip of the iceberg.

Dear Friends.

A good clinical examination is very important and can never be substituted .

With the latest advancement in Medical sciences we tend to become investigation oriented and rush a good clinical examination and often missing things

To conclude it is said that if there is no clue to the  diagnosis go back to the patient. Take detailed history, examine thoroughly and then embark  on any further investigations.