Take a Look at This! Learning to Be A Good Observer

Many times when a patient presents for care, they have a specific problem they want to address. Most practitioners I know will often take a "whole-person" approach and also address other less symptomatic findings in other parts of the body, or treat distal points that do not seem relevant to the complaint (such as treating an ankle for a lower back problem or working with the neck to treat carpal tunnel symptoms). I have shared in the past that treating other areas beyond the area of complaint can be reasonable and appropriate, but that care must be validated. The constantly evolving (Western) healthcare system in which we operate is overtly symptom focused, so there must be a logical process clearly documented for seemingly remote or unrelated care.

In that mindset, it falls on the practitioner to be vigilant when evaluating the patient. Palpation, goading, and orthopedic testing are all important elements of the exam – but don't forget to keep your eyes open and just observe the patient for some of these signs:

• Postural alignment – are the shoulders and hips level? Which side is higher? Is one rotated more forward?
• Head tilt – is the head and neck erect, tilted, or in forward carriage?
• Gait – watch the patient walk (at least into the treatment room, if you don't get the chance to observe them enter the office) Is there a limp? Altered gait? Foot drop or leg swing ?

When the patient is on the exam table observe:

• Postural alignment – shoulder leveling, forward posture, shoulders rotated forward? Do they lean to one side? Do they have problems sitting due to back pain?
• Head tilt – again, observe how they carry their head
• With the patient prone – evaluate for leg length, hip balance, and scapular rotation.

General inspection

In many cases this has become a lost component of examination, but take the time to just "look over" your patient.

I have had many times when a patient denies any surgical history, until you ask them about that vertical scar over the lower lumbars – "Oh yeah, I had a lumbar discectomy, but I forgot about that…" Patients are not always the most reliable historians, it doesn't hurt to take a few seconds to get a general impression.

I should also note here that observation is a key component to assessing malingering in a patient – when their complaints do not correlate with their objective behaviors or actions. When dealing with the feigning or malingering patient, careful observation and accurate documentation is critical.

Another gold nugget tucked is looking at the fingers and nails. Author S. Hoppenfeld notes that the general condition and color of the fingernails can sometimes indicate serious pathologic problems and should not be overlooked during inspection. Normal nails are pink in color, and should be in good condition, neither pitted nor split. The lunula (the little crescent shaped moon at the nail base) should be white. Take note if you observe any of these signs:

• pale or whitish nail beds can be a sign of anemia or circulatory problems
• if the nails appear concave or "dug-out" this can indicate a severe fungal infection
• if the nails appear clubbed – domed, and larger than normal – this can indicate hypertrophy of the underlying soft tissues, but may also indicate respiratory or congenital heart problems.

It becomes very easy to get into a routine and just treat without taking the time to fully assess the patient. There is much that can be learned about a patient from simple observation. There are a number of texts that focus entirely on body assessment through observation.

The body is a wonderful dynamic, and the more we can observe and interpret, the more accurate and focused the care we provide can be. As always, remember to completely and clearly document your findings, correlate with the patient's case history, and logically outline your care plan. These extra notes help document the severity the patients' complaints and can then show the progressive response to care. This extra documentation can also help make the difference if you must justify your diagnosis to an insurer or third party. Take the extra few seconds to add this practice into your exam routine – it will serve you well.

Resources

1. Evans, R.C. (1994) Illustrated Essentials in Orthopedic Physical Assessment St. Louis, Missouri: Mosby.
2. Hoppenfeld, S. (1976) Physical Examination of the Spine and Extremities San Mateo, CA: Appleton & Lange.
3. Kaptchuk, T.J. (1983). The Web That Has No Weaver. Chicago, IL: Congdon & Weed, Inc.
4. Kushi, M. (1980). How to See Your Health: Book of Oriental Diagnosis. New York, NY: Japan Publications, Inc.
5. Lee, M. (1992) Insights of a Senior Acupuncturist. Boulder, Co: Blue Poppy Press, Inc.
6. Legge, D. (1997). Close to the Bone – The Treatment of Musculoskeletal Disorders with Acupuncture and other Traditional Chinese Medicine. (2nd ed.)
7. Woy Woy, Austrialia: Sydney College Press.
8. Maciocia, G. (1995). Tongue Diagnosis in Chinese Medicine Seattle, WA: Eastland Press, Inc.
9. Norris, C. (1996). The Secret Power Within. New York, NY: Little, Brown, and Company.
10. O'Connor, J and Bensky, D. (1981) Acupuncture, a Comprehensive Text. Shanghai College of Traditional Medicine. Seattle, WA: Eastland Press, Inc.
11. Ohashi, W. (1991) Reading the Body. New York, NY: Penguin Group.