INTRODUCTION

The increasing availability of complementary diagnostic tools, together with their growing sensitivity and accuracy, can lead to the relegation of the clinical history and physical examination to a more secondary role. Clinicians were traditionally taught that a thorough clinical history together with a comprehensive and focused physical examination allowed for the diagnosis to be reached in a vast majority of cases^[1]. Internal medicine is a specialty known for its interest in aetiological investigation, and internists are thoroughly trained in medical semiology. However, in recent decades, there has been a reduction in the number of anamneses performed^[2].

CASE DESCRIPTION

A 65-year-old male, with a past medical history of tobacco and alcohol consumption and cerebral vascular disease, was brought to the ER in the setting of a transient loss of consciousness and admitted to the medical ward for aetiological investigation. He had a previous, four-week prior, hospitalisation episode (in a different hospital) for similar symptoms and was discharged with the diagnosis of epilepsy due to presumed alcohol withdrawal.

During the current episode he showed multiple episodes of loss of consciousness associated with bradycardia (minimum heart rate of 25 bpm) and underwent extensive aetiological study including an electroencephalogram (no epileptic activity) and Holter monitoring (no abnormalities, including bradycardia). A doppler ultrasound study of the neck vessels was performed and a stony swelling was identified accidentally in the right cervical region, adjacent to the carotid and jugular vessels.

To further characterise this finding, a CT scan of the neck was performed and revealed an irregular mass involving the Waldeyer’s ring with multiple, enlarged, and necrotic lymph nodes in the right jugular and carotid regions, with invasion of the carotid bifurcation (Fig. 1). A biopsy was performed showing squamous-cell carcinoma. During one of the episodes of loss of consciousness, the patient was aspirated and was transferred to the ICU were he passed away.

(click to enlarge)

Figure 1. Cervical CT showing the jugulo-carotid adenopathies on the right intimately related to the carotid bifurcation.

DISCUSSION

The authors reviewed this case and identified several flaws in the approach. The main flaw was the inability to carry out a detailed physical examination on the hospitalisation episodes. Due to his cerebral vascular disease, the patient only reported a poor clinical history and never mentioned any abnormal neck growth or mass. Despite this handicap, a thorough physical examination involving the neck should have been performed before the accidental ultrasound finding, and prior to all the other studies conducted. We assume that the loss of consciousness was due to vagal stimulation of the enlarged lymphatic nodes with a possible contribution of blood flow impairment due to carotid invasion.

In this case, the diagnosis made during the previous hospitalisation did not influence the approach to the diagnostic progress since the patient was thought of as a first approach; however, we are aware that past hospitalisations may introduce biased thinking. Medical professionals often perceive and report a lack of time for thorough clinical histories, yet paradoxically invest time in ordering and interpreting inappropriate diagnostic tests. In an increasingly technological world where complementary diagnostic tests often allow us to see what is impossible to the eye, the physical examination is often neglected.

In medicine as in every other profession and in life, acknowledging mistakes is often difficult. However, as practising medical doctors, the task of reviewing cases where a subpar approach is noted is essential, as these are the cases that most often remain in our memories and shape our future practice. The authors share this case as a means to emphasise the importance of the physical examination in light of all the recent technological advances and also the importance of acknowledging, reviewing and learning from past mistakes.

1. Guimarães, F. Which is the real contribution of the clinical history to the diagnosis? Medicina Interna 2011;18:267–268.
2. Peixoto Filho AJ. The rise and fall of of the physical exam. Brasília Méd 1999;36:13–16.