The Lost Art of Bedside Diagnosis: What a Thorough Physical Exam Should Include

Introduction to the Balancing Point 0:00

Doctors should be picking all of these things up before they ever run a lab. Posture, if I were talking to them and they weren't just kind of lounging in front of their computer, they're attempting to open the back of the spine. So if they have a spinal problem, a disc, it's probably on the, If they were sitting kind in a military fashion with their belly pushed forward, It would probably be an attempt to the other side of this. Again, very telling. Hi, and welcome to The Balancing Point. I'm Dr.

John Needers. And I'm here to make traditional Chinese medicine, functional medicine and integrative health simple, practical and fun. So you can restore balance, boost vitality and enjoy a healthier life every single day. Hi there, this is Dr. John and I am back with another episode of The Balancing Point. This one will be a moderate length, but I think it's pretty fun for you to watch. And this has taken from a course that I teach. fairly regularly and also I was inspired by a book that my wife gave me.

Now, when I see a patient, it's usually a three-part exam for me, I have a scribe that's taking notes. I will do a general seated visual exam that I'm going to go over with you. Then I'll do palpation, which in this case seated is mostly taking their pulses in the Chinese medical way. And then we take them into the other room, have them lie down, and we do variety of other exams there.

Three-Part Patient Exam Overview 1:28

Now, occasionally we add orthopedic or gait testing, et cetera, but very, very rarely in my part of the practice, I have several really skilled, sports medicine, orthopaedic practitioners in the office that do most of orthopaedics. My wife is the acupuncturist for the San Francisco 49ers, St. Mary's rugby team, she teaches all over the world. She treats athletes from all of the other world, so she's got it pretty well handled. So I get to stay in my lane and do what I do. Now, when I see a patient, well, before I got to that, my wife gave me this book called Bedside Cardiac Diagnosis done by Henry Marriott.

And Henry is a cardiologist from the United Kingdom. My wife kind of giggled when she gave it to me and she pointed to a particular section and I saw why she giggling. He went on a rant. Henry was just going on and on about how cardiologists had lost their ability to do bedside diagnosis. He said they've gotten too reliant on technology and they miss too many things and their patients suffer needlessly. Well, I've gone through that rant many times in front of my wife and she's seen my process, so she knew I'd appreciate this.

So, gait analysis. Now, this doesn't have to be formal. In fact, we don't do them, I don' do the formally, my wife does. What this involves is I will stand up, walk out in the hallway, and we have a fairly long hallway back to my office, And I'll watch people walk. You can tell a whole lot about what's going on in terms of injuries, in term of illnesses, In terms their attitude, whether they're depressed, Whether they are happy, etc. All these things just watching them walk into your office. Then I'm going to shake hands.

Yay. Well, what can you tell from that? Do they have any strength? Are they weak? are they hot? or are cold? Or are their hands clammy? So all of these things that you can tell by a handshake. You can get a lot about their attitude also. So then from a Chinese standpoint, we have a LOT of advantages that Western medical doctors don't.

Observational Diagnosis: Gait, Handshake, and Facial Clues 3:43

So here we're looking at a map of the different zones on the face that corresponds to different organs. There's one of Katherine, my associate's favorite favorite teachers, was a woman named Lillian Bridges who passed away a few years ago who was brilliant at this. I had a couple patients that I told about Lillion. They went up to see her in Seattle. She diagnosed exactly what I had diagnosed just by looking at their face. And she told them a lot more stuff also about kind of their personal life and things.

So it can be quite astonishing. Again, here are some of those zones. You can look back at these at some time. And you get these different areas. So we look at acne, and sometimes it's the large intestine. Sometimes it is the stomach. sometimes It's a small intestine, but you can tell what's out of balance just from looking at their face. Now, I'm going to follow that up with a dozen, a hundred other tests. I am going read their labs. I haven't even started yet. I hadn't started interviewing them yet and I have all this information.

Then you've got your eye processing patterns. Those of you that have done neuroassociative conditioning or looked at neurocode systems, you know that people when they're accessing their brains in different ways will look in difference quadrants or different areas with their eyes. So if you ask them a question, what did you have for breakfast this morning? And they look up to the left, then they're seeing their breakfast. If they looked off to side, to left then, they are talking to themselves actually about their break.

And so then you can see if they lying, if go from recalled to constructed and then tell you a story, right? So again, This can be very helpful. And one of the reasons it's helpful is it helps the doctor access their predominant styles of listening. It's like if someone speaks Spanish, it is not very effective for me to speak French to them, unless they also know French. So I want to be able to their language. This is an ear coloration chart. I'm not going to go into the details, but looking at the ears and seeing different colorations is very powerful.

here on this fellow. Now you can't see it very well, but There's a line out there, earlobe, okay? It's called a diagonal ear lobe creasing, and it's positive correlation to atherosclerosis and coronary artery disease. Now, it is not a tremendously high correlation, but there is a correlation. Again, I can't point here, if you look at the very apex of this gentleman's ear, you see a big black spot. That's the point for high blood pressure. If you come down around the back of the ear, you're going to see several other black spots.

And if you look more in the top, about one third of way down from the tip of your ear you see a white spot and you'll see some more black spot. Those are all diagnostic. Now here we've got skin tags. This is often type 2 diabetes or too much insulin.

Eye, Ear, Skin, and Posture Indicators 7:10

Sometimes it's just genetics. And here you see xanthalasia. swellings at the upper inner canthus of the eye. Now if you see all three of those, if he sees xanthalasia, skin tags, and franksign, those three together, there is a proven positive correlation to atherosclerosis and coronary artery disease. You see, all 3. Here's corneal arcus, you're staring at your patient. or you're the patient being stared at, and you see these white areas around the cornea. And that's an indicator generally of very high cholesterol levels that have settled into the vessels.

Here's thyroid ophthalmopathy or Graves' disease. You see how the eyeballs are bulging. Probably the classic example of that, it was the actor Marty Feldman. He was in Young Frankenstein and a few other movies, and he had very clear Grave's disease eyes, okay? Now again, your doctor should be picking all of these things up before they ever run a lab. Posture, this person very possibly, you know, if I were talking to them and they weren't just kind of lounging in front of their computer, they're attempting to open the back of the spine.

So if they have a spinal problem, a disc, it's probably on the rear. If they were sitting kind in a military fashion with their belly pushed forward, It would probably be an attempt to the other side of spine, so again, very telling. Okay, you're gonna look at muscular tone and balance, skin quality, pulse oxygen, nails, palms, and then channel palpation of the end channels, which I'm not gonna have time to go into today, but. These are all things you look for. Now, these pictures came out of Wikipedia and they always show the most severe cases.

If you had nail clubbing like this, you would have already been diagnosed. Your doctor couldn't miss this. But you see many minor cases of lung clubing, I mean of nail-clubbing, and you can catch it early, like here. This is called the shamroth window. You can see a little window there. a little kind of diamond-shaped window where you can see white between the nails. If that disappears, that means there's nail clubbing. These are really easy to spot if you look for them. I've never had a doctor look at them, so these are small blood clots.

It's called a splinter hemorrhage because it looks like a Splinter. And when I point them out to people, they swear they're splinters, but there is no splinder. So these tiny bloodclots, that are getting trapped in these tiny, tiny capillaries in the fingers. And this is really about the only place you can see them because you see through the nail and see the clots. Now this often infective endocarditis. It can also be cancer, et cetera. That just means let's look deeper and look quickly. Okay, I'll leave these up here.

I'm not going to go through all of them, but you're welcome to come back and take a look at them. But each of these nail and nail bed colors can tell you something. So this is a baby with a heart disease. You can see the red fingertips. Here we've got cyanosis, the blue from very low oxygen levels. Here we've got onycholysis. Lysis means to break down. And you see the nails are, this isn't just typical like biting the nail.

Nail, Hand, and Finger Findings 10:48

This is from psoriasis, or it can be due to a thyroid problem, thyrotoxicosis. You don't really see it much, but there are also a couple white spots on the nailed beds, which is usually, not always, usually a zinc deficiency. So you want to look at the nail and the nailed bed color. So here we've got these alternating lines. These are called Mies lines and they can show up if there's arsenic or thallium poisoning and sometimes in kidney failure. Fortunately, they are not very common. Bose lines, this is much more common, This is a horizontal area of depression, and this is non-specific, but it means something really bad happened.

Heart attack, stroke, death in the family, something that was so shocking that the body would not put energy into growing fingernails at that time. And you can see it. I have patients, I'll go through their history. but I'll look at their nails and I go, something severe happened to you like six months ago. Oh yeah, you know, this and that happened. I got in a car wreck and, I was hospitalized, but they hadn't put it on their history, right? But the Bose lines don't lie. Vertical nail ridging, that can be many different things.

Again, too many to go into in this presentation. And then physical exam of the hands and fingers. Heberdeen's nodes, that's where the distal interphalangeal joints, the joints closest to the nails, get swollen and hard. Sometimes painful, sometimes not, but that is really a sign of osteoarthritis. Ehlers-Danlos, I will pull on people's skin, you know, to see how much stretching and flexibility they have, because most of the patients I see with Ehler's Danlos have not been diagnosed by their doctors when I seen them.

Here's some hypermobility, often associated with ehlers Danlo, but not a hundred percent. Dupuytrenes contracture, You can see there on the fourth finger, the ring finger. There's a. a bump there, which is where the connective tissue has become damaged. Dapertrains contracture. This is a gene that was passed around the Atlantic around Great Britain, et cetera, by the Vikings. That was very kind to them. Here you have Osler's nodes. Now again, this one's really extreme. The one like on the index finger is much more likely to be found.

This is an immune complex deposition. I mean, something's, really messing with your immune system. Effective endocarditis is often the cause of a Janeway lesion and these are very subtle. It's not like the Oslar's node or like, wow, I can't miss that. this ones easy to miss. It's almost always missed because doctors don't look at your hands. Rheumatoid arthritis, that's obvious. Now the art of pulse taking. Probably the single most important thing from a Chinese medical perspective is pulse-taking.

We check three or four positions. Some people even check five on each wrist and we look for the depth, the quality, there are 28 pulse qualities. So when you multiply that out, got 9 to 15 on each hand and then you've got them on both wrists and you put those together. This is an amazing diagnostic tool. We'll look at the tongue. When we look the top of the Tongue and underside some lingual veins. These are Chinese medicine things. Tongues diagnosis. If this is a female, severe premenstrual syndrome.

So you see the area in the middle of the spleen and stomach is very depressed. It's indented. The area on the sides, the liver gallbladder is swollen.

Tongue and Mouth Diagnosis 15:00

That's a sign of an earth-wood disharmony or liver assailing the splen and the stomach. And that will cause way, way horrible PMS. There's also a little bit of a heart cleft here. This person could easily suffer from anxiety. This is really a bad one, this is a tongue of a breast cancer patient. You see the swelling there, very unusual, but that's a very clear indication. Here we have glossitis, that red tongue. This can be any number of B vitamin deficiencies, But it can also be from inflammatory bowel disease like Crohn's disease.

And then you see that horrible patch of Candida there. Okay, we had angular chelitis. That's where you have redness at the corners. That can be caused by anything from anemia to infection. Leukoplakia. Now your dentist will hopefully pick this up. I've never had a doctor look in my mouth. And this is a precursor to mouth cancers. Gingivitis. At the top, you can see the damage. The bottom you see when it's cleaned up, very important because gingivitus is one of and maybe the leading cause of heart attacks.

Way, way, more important than cholesterol. And I'm not saying cholesterol doesn't play a role, but gingivitis and gum infections are much more dangerous. Then we'll take them in the other room. We will do a physical exam. Murphy sign. So we reach under there. You can see that green in their little green place. It's the gallbladder. We'll have patients breathe in, exhale. I'll put my hand up under their ribs, press on the Gallbladder, and if it's hot, they'll scream at me. Okay? So, we're going to check that.

And we'll palpate over the liver. we are going check for the livers size. If I'm suspicious, I will do what's called the hepato jugular sign where We put them at a 45 degree angle. We press on the liver and you'll see changes in the blood vessels in their neck. Here's a picture, but it's not a very good picture. There are lots of very, good videos on this. Blood pressure. should always be a minimum of both arms. Always be minimum a both arm. You might want to do all four quadrants if you're suspicious of peripheral vascular problems.

Abdominal, Cardiovascular, and Blood Pressure Exam 17:28

I use just a general electronic measuring device for my general checks. And I used a cuff and a stethoscope if I find something abnormally high or to confirm other findings. Stethoscope, I'm going to listen to their heart sounds, bronchial sounds and intestinal sounds. Now we're getting into things that doctors will do more often, but still. It's very rare to do intestional sounds here's the heart map. Physical exam, we're going to look for Morton's toe. That's where the second toe is longer than the big toe, and here it's called short big toes, but it can actually also be long second toes.

And that will cause several gait problems over time. So it is nice to know it. Notice it? Mortons neuroma, again named for Dr. Morten. is actually a calcium deposit that gets around the nerves and you can see it there between the third and fourth toes. It's a Calcium deposit and those can hurt like heck. Chronic venous insufficiency. I'll check every patient's legs and feet to make sure they're not getting vein breakage. This is very serious. Venous stasis dermatitis. Diabetic shin spots. Often people don't know they are diabetic, but this is another Symptom, saphenous vein thrombosis.

Now, I've had patients that had no other symptoms other than a little cramping on the medial portion of their calf. I checked them. They had an obvious saphanous veins occlusion. It feels like a hard pencil. If you know what it feels, like you can't really miss it. And then we'll do, look for general eye pupillary examination, the stagmas, that's where the eyes bounce back and forth. The pupil's accommodation to light and something called a PPR, which is a paroxysmal pupillary reflex. Now this I will do when there's a concussion or I suspect a conjunction, but it also can happen from brain stem and tumor issues.

And the bottom line is when you shine a light into the eye at an angle, so your darkened room, shine the light. The pupils should hold the contraction for 30 seconds. If they don't, there's something wrong. And one of the things that I didn't list here is severe adrenal fatigue. The adrenals just aren't providing enough energy to keep the pupils contracted. So there is basic eye exam. Raglan's test, we do this on most patients. If you have a postural change from lying to standing, it should increase the blood pressure by five to 10 points at two minutes.

Some doctors prefer three minutes, I do it lying down. Then I'd do a 30 second standing because I want another thing.

Legs, Feet, and Orthostatic Testing 20:38

I wanna see how the adrenals are responding. And then two minute standing. Adrenal fatigue, the lower the number, Well, anyway, if they drop, so I get a lot of chronic fatigue patients who their blood pressure will drop 30 to 35 points when they go from lying to standing. That's very, very dangerous and very bad. They can get orthostatic hypotension from low blood volume and pass out. So there are a couple of things we wanna check with that. So that's the end of the presentation. These are ways that you can get in touch with our office.

And I wanna thank you if you sat through all this and start expecting more from your doctor, whoever it is. I don't care if it's an acupuncturist, a chiropractor, an MD, start accepting more them and make sure they're really giving you a thorough examination. Until next time, be happy. Be healthy. See you soon. Bye-bye. Thank you for joining me on The Balancing Point. If you enjoyed today's episode, please follow the show, share it with a friend, and leave a review. Feeling out of balance? Most approaches just manage symptoms.

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