Observation is a vital part of a correct prognosis and treatment. In this article, Dr. YK Amdekar explains the importance of observation and 7 cues to look for with the help of a few case studies that further help in selecting the right course of treatment, especially in emergency cases. 

Clinical examinations should begin with observation. Observational skills are useful in medicine as much as they are useful in every sphere of life. Most of us see but do not observe, and hence miss important clues that would help in diagnosis. Seeing is at the retinal, but observation is at the general cortical level. We need to cultivate such skills.

Physical examination should start with observation and it is an important part of the examination of every system. In fact, you can observe as a patient walks into your room and also while history-taking. Technology is no substitute for focussed physical examination and observation leads the way to focus in the correct direction. A first look at the patient can decide the level of urgency to act that may save a life. In this article, we will see how observation helps in case of an emergency.

Suspecting “seriousness” in a patient: 7 things to observe

1. The first look: First look at the patient would suggest to an experienced observer that something is amiss and pave the way for astute observation.
2. Appearance: Irritability, restlessness, drowsiness, state of confusion and irrelevance, delayed or no response when talked to, indicate early brain dysfunction. Once it is noted, one can proceed further to define the cause that could be an impending shock (due to various diseases) or metabolic disorder (electrolyte or acid-base imbalance, hypoxia, hypercarbia, hyperglycaemia or hypoglycaemia).
3. Airway: Unobstructed breathing without noise or making noise (hear stridor denoting inspiratory upper airway obstruction, wheeze expiratory lower airway obstruction, grunt denoting need for better oxygenation or bubbling sounds suggestive of secretions in upper airway).
4. Breathing
   1. Respiratory rate – Normal or increased (rarely decreased as in case of cerebral depression – an ominous sign). Deep and rapid respiration denotes metabolic acidosis.
   2. Chest retractions – Suprasternal (upper airway inspiratory obstruction), intercostal (lung parenchymal disease such as pneumonia), subcostal (lower airway expiratory obstruction). In addition, other accessory muscles of respiration may be active that together denote increased work of breathing.
   3. Abnormal pattern of breathing – Cheyne-Stokes breathing and Biot’s breathing suggest serious brain disorder.
5. Circulation: Pale periphery suggestive of poor peripheral circulation – may indicate shock or also seen during rising fever (general paleness in severe anaemia).
6. Skin rash: Purpuric or gangrenous skin rash, as well as haemorrhagic bullous rash, are indicative of serious conditions.
7. Few other observations: Sunken eyes suggest dehydration that may need fluid resuscitation. Pithed frog-like position indicates generalised hypotonia that may denote probable severe hypokalaemia which may demand urgent potassium replacement.

The above-mentioned facts can be observed only if you have an eye for it to suspect the seriousness and plan for urgent intervention. The following examples would reiterate the importance of observation that could help save a life.

Case 1

A 10-year-old child woke up out of deep sleep at 4 am with uneasiness and was noticed to have a high fever. Paracetamol and tepid water sponging brought down the fever for a while but he started talking irrelevantly and could not recognise his mother. The child was brought to the hospital and a physical examination showed drowsy child with tachycardia.

Acute onset of brain dysfunction in a child with high fever suggested probable meningococcal infection and IV penicillin was started with fluid resuscitation. The diagnosis was confirmed and the child survived. If this early stage was missed, it could be fatal in the next 12 hours with shock and multi-organ failure.

Case 2

A 2-year-old child presented with diarrhoea that was partially controlled by administering ORS but developed quadriparesis and tachypnoea. A mere look at the child was enough to know that all the limbs were flaccid without movement, the respiratory rate was fast but very shallow and the child had no voice while crying.

It denoted severe hypokalemia resulting in general muscle paresis including respiratory muscles and required IV potassium to salvage the life-threatening condition. It is rare to need IV potassium in a small volume of fluids but whenever required, it must be done under cardiac monitoring to prevent cardiac arrhythmia.

Case 3

A 12-year-old child presented with a high fever and mild cough followed two days later by sleepiness. On observation, the child was responsive when called but when asked where his father was, he could not find him though he was next to him. This is a state of confusion.

High fever preceding this event meant a complication of probable infection and mild cough suggested respiratory infection. On further close observation, the respiratory rate was 28 per minute that denoted probable hypoxia as a cause of his state of confusion. He improved when he was put on oxygen.

Case 4

An 8-year-old child presented with acute onset of drowsiness over the last few hours. He was apparently well prior to the onset of this problem. On observation, he was drowsy but would open his eyes when called but did not respond any further.

On closer observation, his breathing was rapid and deep but without respiratory distress that suggested metabolic acidosis. As it happened in an apparently normal-looking child, diabetic ketoacidosis was considered and also proved on relevant investigations. On direct questioning thereafter, his mother had noticed excessive thirst and water intake.

In summary, observation is a clinical skill that all doctors must develop by repeated practice. Unfortunately, it is rarely taught or focussed during medical education. As demonstrated in the above-mentioned cases, it can help avert a life-threatening situation with the immediate appropriate action.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.