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Year : 2016  |  Volume : 3  |  Issue : 3  |  Page : 226-228

Old is still gold…knee hammer: A forgotten tool!!

Department of Pediatrics, Sri Ramachandra Medical College, Porur, Chennai, Tamil Nadu, India

Date of Web Publication9-Jun-2016

Correspondence Address:
Julius Xavier Scott
Department of Paediatrics, Sri Ramachandra University, Porur, Chennai - 600 116, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2348-3334.183752

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In this era of the latest diagnostic technologies, meticulous clinical examination of the patient still is the golden principle of medical science and will never lose its importance. This case report highlights that detailed physical examination of the patient would have led to the identification of the etiology quite earlier and the significance of evaluating a child as a whole and not based on symptoms alone.

Keywords: Clinical examination, fundamental of medicine, spinal cord tumor

How to cite this article:
Sneha LM, Ravindran M, Ramachandran P, Scott JX. Old is still gold…knee hammer: A forgotten tool!!. CHRISMED J Health Res 2016;3:226-8

How to cite this URL:
Sneha LM, Ravindran M, Ramachandran P, Scott JX. Old is still gold…knee hammer: A forgotten tool!!. CHRISMED J Health Res [serial online] 2016 [cited 2022 Aug 8];3:226-8. Available from: https://www.cjhr.org/text.asp?2016/3/3/226/183752

  Introduction Top

The more complex the technology becomes, the more the basic skills are needed and the more difficult to restore them once they are lost. The significance of clinical methods must be preached, practiced, and should never lose its priority. This case not only brings out an unusual cause of diarrhea but also an emphasis on the value of good history taking and thorough clinical examination of every patient irrespective of the clinical manifestation.

  Case report Top

A 1½-year-old girl developmentally normal child was admitted with diarrhea of 3 months duration, not associated with fever or vomiting. She was treated symptomatically with intravenous fluid, zinc supplements, and lactose-free diet before coming to our hospital. The child was reported to be irritable, and it was attributed to the perianal erosions. Although the mother pointed out that the child was not walking, hypokalemia was suspected to be the cause. Due to persistence of symptoms, the parents had consulted multiple pediatricians. On examination, the child was found to be irritable with an inconsolable crying. Her vital signs were stable. Anthropometry revealed a weight of 7.6 kg and length of 75 cm, which were <3 rd centile. There were no signs of dehydration. Complete blood count, renal function tests, liver functions tests, serum electrolytes, tests for malabsorption, urine routine, urine culture, stool routine, and stool for reducing substances were inconclusive.

While the child was being subjected to this armamentarium of tests to rule out other causes of diarrhea, with the mother's repeated concern that child refused to walk at the time of onset of complaints was now given cognizance, and a detailed history revealed that the child had lost not only motor milestones of walking but also sitting without support and standing without support. A complete central nervous system (CNS) examination done revealed the decreased spontaneous movements of lower limbs, weakness of both lower limbs with a power of 2/5 in bilateral proximal and distal muscles of the leg, absent deep tendon reflexes, and loss of anal sphincter tone.

A magnetic resonance imaging of brain and spine was done which revealed an intramedullary tumor extending from T4 to conus medullar is with features suggestive of spinal ependymoma as shown in [Figure 1]. The symptoms of chronic diarrhea and weakness of lower limbs could all be attributed to the spinal cord tumor (SCT) compression thereby producing bowel and bladder incontinence and pain which could have been the cause of the irritability in the child. The case was discussed in our tumor board with neurologist, neurosurgeons, radiation oncologist, and pediatric oncologist and due its extensive involvement of spinal cord, surgical resection was rendered practically impossible. Therefore, the child was advised palliative care.
Figure 1: The sagittal T2-weighted of the whole spine showing an intramedullary T2 hyperintense involving the entire spinal cord and expanding it

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  Discussion Top

In spite of many modern refinements and an increasing number of laboratory investigations, the history and physical examination will remain the cornerstones of the physician's daily work the rest of his life. All over the world, thoughtful history taking and physical examination are recognized as fundamental to the practice of medicine. [1],[2]

However, when forced to live in a current era, where the patient's confidence and belief in the treating physician are spiraling down, it is no wonder that medicine practitioners have resorted to newer diagnostic techniques as they are more accurate than the subjective physical examination and less liable to litigation. We have to admit that with the advent of newer imaging techniques, we have been able to establish diagnoses with speed, accuracy, and safety never before imagined. However, overreliance on these technologic marvels has crippled physicians' use of the mind and the clinical skills to make diagnosis.

This case is a perfect example of importance of good bedside clinical skills as the identification of the findings during the physical examination might have the improved the timeliness and hence, the quality of care thought it might not have affected the final treatment decisions.

Although tumors of the CNS in children constitute the second most prevalent tumor type of childhood, SCTs account for <10% of pediatric CNS tumors. [3] SCTs generally present as low back pain, motor regression, gait disturbances, sensory loss, kyphoscoliosis, or torticollis depending upon the level of spinal involvement. [4] Bowel and bladder incompetence causing chronic diarrhea and recurrent urinary tract infection as the initial manifestation of the SCT are less reported in literature. Being a young child with limited capability to express the problems, the history of pain and weakness of lower limbs was probably missed out in this case.

Ependymomas are an uncommon group of glial tumors that typically arise within or adjacent to the ependymal lining of the ventricular system. In children, approximately 90% of ependymomas are intracranial, including 60% located in the posterior fossa, while the remaining arise in the spinal cord. Tumors involving the spinal cord present with deficits due to the involvement of ascending or descending nerve tracts or the existing peripheral nerves. Specific abnormalities are related to the anatomic level of the tumor. The diagnosis of ependymoma requires histologic confirmation. The initial treatment for patients with ependymoma arising in the brain consists of maximal safe resection, usually followed by adjuvant radiotherapy. [5]

  Conclusion Top

Medicine based on a carefully constructed medical history, coupled with a pertinent physical examination and critical assessment of the information obtained there from gives a good reasoning power and thereby aids in a good management plan. Bedside diagnosis can be an effective supplement to the present diagnostic armamentarium and particularly worthwhile in an era of progressive loss of the patient-physician relationship.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Nassar ME. Hyposkillia: Deficiency of clinical skills. Tex Heart Inst J 2005;32:623.  Back to cited text no. 1
Fred HL. The downside of medical progress: The mourning of a medical dinosaur. Tex Heart Inst J 2009;36:4-7.  Back to cited text no. 2
Stiller CA, Nectoux J. International incidence of childhood brain and spinal tumours. Int J Epidemiol 1994;23:458-64.  Back to cited text no. 3
Hsu W, Jallo GI. Pediatric spinal tumors. Handb Clin Neurol 2013;112:959-65.  Back to cited text no. 4
Benesch M, Frappaz D, Massimino M. Spinal cord ependymomas in children and adolescents. Childs Nerv Syst 2012;28:2017-28.  Back to cited text no. 5


  [Figure 1]


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