Clinical exams in the time of COVID-19

June 4, 2020

“It is not what you look at that matters, it’s what you see.” Henry David Thoreau

Observational skills are a vital tool in the medical profession. We are taught to pay attention to key words, phrases, and important visual cues as patients relate their histories. Along with this comes our gold standard - observations during clinical exams. Physicians are accustomed to looking at patients and identifying predictable patterns within our learned disease registries. 

Examination

We refer to a variety of valuable online resources when what we see doesn’t fit a remembered pattern, or respond in the manner we expect it should. I would not say that physicians are rigid in their pattern recognition or treatment regimes, but we are certainly comfortable and familiar with disease patterns. A particular symptom matrix generates a particular differential diagnosis. This diagnosis is the key to managing the patient sitting before us. We know when to consider alternative or co-existing diagnoses. We know when to ask colleagues with more in-depth knowledge of certain body systems for assistance when needed. Years of training and clinical experience reinforce these important diagnostic skills. 

With the entrance of SARS-CoV2, much has changed. What in the past was clinically identified as a “common cold” or “flu-like illness” warrants further investigation, generating anxiety in patients and providers alike. Beware we say, this could be COVID-19. We must take extra precautions and manage this differently, not only to give the patient the best care possible, but to protect ourselves and those around the ill contact. We ask: Where have you been? Who have you been in contact with? As physicians, we now know this new pattern, and have adapted accordingly.

We know that SARS-Cov2 is complex. It is not limited to respiratory illnesses. Facing this new illness, how do we quickly adapt our internal disease registries, when this infection mimics so many other disease processes? 

A few weeks ago, I sent a middle-aged patient to the emergency department from my office for undiagnosed abdominal pain. Of course, it was late in the evening, and nothing could be worked up for them as an outpatient. Significant fever and respiratory symptoms were not part of the initial presentation, but vomiting, loss of appetite and persistent abdominal pain were. I have to admit that I had not really considered COVID-19 as a leading diagnosis, however as the SARS-CoV2 disease spectrum is now so broad, my emergency physician colleague rightly asked that question.

The implications for personal protective equipment and isolation are significant in both the emergency and imaging departments. The patients’ symptoms needed to be fully assessed and the differential diagnosis needed to be developed. No one wants to miss other underlying disease processes while we wait to learn whether or not a viral swab is positive on every single patient. Yet this is the new reality for so many with undifferentiated symptoms, and perhaps even those that are more differentiated. 

There is simply so much that we do not know about this virus. Coronavirus symptoms are associated with abdominal, circulatory, dermatological, and neurological presentations, separate from overt respiratory symptoms. We are learning to retrain our brains to see beyond our usual patterns, and respect the potential for Coronavirus across disease spectrums. A stroke, MI, DVT, or skin rash may indeed be COVID-19 in disguise. There are significant implications for front-line practitioners regarding PPE, safe spaces for examinations, and cleaning requirements, both in the community and in our hospitals facing this broad disease spectrum. 

In time, SARS-CoV2 will reveal its many secrets. As we continue to increase our knowledge and experience with this evolving disease, we will become more comfortable in our pattern recognition, diagnostic work-up and treatment. We will continue to incorporate new information and adapt accordingly. 

In the meantime, physicians are looking beyond what is in front of us and seeing the potential. For the foreseeable future, we will maintain a high index of suspicion, rigorous infection control measures, and test generously, to better understand the full spectrum of this novel coronavirus. This is not a sprint to the finish, we are in a marathon that is unprecedented in our time. Stay safe.


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