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A good clinical examination clinched the diagnosis

Greetings of the day 

Down the track of memories

Today story from Sir Ganga Ram hospital New Delhi

Years back while working as 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 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 refrence to internal medicine for advice.

"Ibrahim! Let us see the patient", said Dr S P Byotra  and together we went to see Mr Raj on the 3rd floor  ( the semi nursing home) of the hospital.

" Hello  ji" Dr Byotra 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 scrutinizing 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, Dr Byotra 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 Dr Byotra .
 The work up used to be very swift in this hospital. 
The lymph node was taken out and sent for histopathology.
Next day the reports were ready.
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 never done as it was never required. 
The patient s 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 latest advancement in Medical sciences we tend to become investigation oriented and rush a good clinical examination often missing things

It is said that if there is no clue to the  diagnosis go back to the patient. Take detailed history, examine thoroughly and do not embark  on any further investigations before.