The Dilemma of the Physician, Going Back to The Clinician, Back to Basics

Abstract

Background: Technology has allowed the scientific side of medicine to evolve more rapidly causing the “modern” physicians to greatly rely on laboratory values and imaging studies thereby leading to the loss of clinician abilities and skills. Case: A 52-year-old female with multiple cardiovascular co-morbidities including ischemic heart disease, presented to the emergency department in the morning with diffuse body pain associated with malaise, numbness and paresthesias of the right upper and lower extremity. This was followed by an “out of body” sensation. She then experienced transient sharp left-sided chest discomfort described as moderate to severe in intensity with a duration of approximately 2 minutes slowly subsiding on its own. Subsequently, she reported difficulty lifting the right hand and leg as well as slurred speech. The strength in her limbs returned within the hour but numbness and paresthesias persisted and continued to bother her. At the time of presentation, she was hypertensive but no other abnormalities were found on the physical examination. An elevated troponin level was noted but acute coronary syndrome (ACS) was unsuspected in the 12-lead electrocardiogram (ECG). A noncontrast computed tomography (CT) of the head was unremarkable. A subsequent 12-lead ECG revealed new T wave inversions in the lateral leads. This provoked a repeat neurological exam in greater detail, and there was objective weakness of the distal muscle groups of the right upper and lower limbs. The NIH score was now 6 (prior was 0). Brain magnetic resonance imaging (MRI) the following day showed an acute infarct of the left internal capsule. Approximately 72 hours after the initial presentation, the patient remarkably improved and was planned for discharge by the 5th admission day. Conclusion: Clinical skills are crucial in the technological era; it could definitely prevent mistakes or time matter diagnosis. Hence, a reason why in times of dilemma, a return to the basics promoting these skills will always be helpful.