Bedside Medicine as Guideline for complete Diagnosis and Management


Book Review

Bedside Medicine as Guideline for complete
Diagnosis and Management

This second edition of Gen. Arshad Mirza’s Book provides lot of
useful information and is an excellent guide in patient management

ISLAMABAD: Lt. Gen. Arshad Mirza a noted physician, Professor Emeritus at Army Medical College and Armed Forces Postgraduate Medical Institute has published the second edition of his book on Bedside Medicine. This book was first published in the Year 2000 and later Melrose Press UK published this book after re-arranging the text and editing to make it still more useful for the readers. The author has now published its second edition with the addition of seven new chapters covering diagnostic process. Going through the book makes an interesting reading and the physicians as well as medical students; postgraduates will find it extremely useful in not only patient management but also a useful source of quick revision as well.
Today the physicians tend to rely too much on technology and are quick in asking a number of investigations some of which are quite expensive and many of these investigations may also be un-necessary. Doctors appear to have forgotten the importance of good history taking and comprehensive physical clinical examination which most often provides diagnosis in a large number of cases and investigations are ordered just to confirm the diagnosis. Clinical Skills are no more taught to the medical students as they used to be by some of the eminent medical personalities in the past. Writing in the Foreword of this book’s First Edition, Prof. Ian Gilmore had stated that “this book has put clinical history and examination back where they should be- at the centre of patient management”. The first chapter in the book contains lot of pearls of wisdom and Prof. Ian Gilmore had rightly recommended that “this chapter on history taking contains clinical pearls so often missing from such books, such as finding the real motive for a patient seeking help. This may be quite different from their presenting complaints.”
This book is the result of the author’s decades of rich experience in medical practice and the first chapter in particular, needs to be read again and again which will help improve patient care to a great extent. Physicians are supposed to keep themselves abreast of latest developments and continue learning throughout their life; hence it also offers a quick revision. Repeated reading is also important for better understanding, retention in memory and gain confidence in application of the knowledge gained which ensures good results. Lot of new developments has taken place in Medicine in the last ten years. Many new diseases have been discovered and better understanding of physiological processes, chemistry, pathogenesis, pathology and many other changes in body’s system and their detection has opened opportunities for numerous new sophisticated investigations. They are all helpful in diagnosis, assessment of severity besides detection of various complications. Some of the physician has developed the tendency of ordering a few tests even before proper examination of patients which is now becoming common and all this is not in line with ethical medical practice. Many patients have symptoms which can be diagnosed clinically after thorough history and clinical examination. Moreover many symptoms may be more painful for the patients which they will only disclose when asked to during the examination. All this requires a thorough and deep search into the nature of the symptoms, following general and systemic examination which may reveal something accidentally not directly connected to the presenting symptoms. At times the patient deliberately does not disclose some symptoms for certain reasons and this information has to be extracted during the interview while taking history.
Lt. Gen.Arshad Mirza says that while the doctor is examining the patient, the patient is also examining the doctor. Hence gaining the confidence of the patient is extremely important for compliance with the instructions and follow up for ultimate cure. All this depends a great deal on doctor’s interview with the patient and examination. Too much and overuse of modern gadgetry not only diminished contact with the patient but also diminishes the patients internal feelings and emotional responses.
The author has also quoted Dr. Louis H. Clerk retired Surgeon from Jefferson Medical School Philadelphia USA. He was aware of the dangers of relying too heavily on technology hence he repeatedly expressed concern that “physicians must avoid the pressures that would convert them into mere technicians who might become too accepting laboratory results and too complacent in their approach to patient evaluation”. The main objective of writing this book, Gen. Arshad Mirza says is to “reinvigorate interest in the form of rapid reading in the process of bedside medicine which not only provides guidance towards the main disease but also helps in assessing other signs and symptoms which is vital in total management of the patient.”
The book has been divided into seventeen chapters i.e. medical case taking, general physical examination, Systemic examination, examination of the cardiovascular system, Respiratory system, Alimentary system, nervous system, locomotors system, endocrine system and metabolic disorders, and Blood. The new chapters which have been added in the second edition include normal features of human being and their functions, diagnosable features for clinical diagnosis, control of various system, points for history, symptoms and signs self expressed or discovered in history and examination, differential diagnosis of various systems, scientific basis of faith healing- the role of Psyche in physical ailment and of Faith in treatment.
Some of the important points which the author has highlighted in the First Chapter in medical case taking are when there is a call to visit a patient, one must respond, urgent calls should be answered urgently, examination place should be quiet, pleasant and well lighted. Allow the patient to describe his/her symptoms for at least one or two minutes without any interruption. Keep professional attitude but avoid being overly formal, be sympathetic and understanding. Be patient in hearing the story, use good manners during examination, search for symptoms, ask for previous history of illness, treatment history, and family history, during examination take a general look rather than zooming over a particular area, if diagnosis is fairly clear, cut short questions and examination. Treatment should not be withheld till the final diagnosis is made. Do not resort to carrying out all test indiscriminately, consider availability and cost of the tests. When necessary seek advice or help and interest of patient should always be uppermost in doctor’s mind.
Marital history, personal history needs to be inquired. Working career, home environment, personal habits like use of tobacco, chronic constipation, insomnia and use of drugs, how often and how much will provide lot of useful information. While taking history about paediatric patients, infants and children, take family history from the mother. While examining adolescents first examine them privately, use extra sympathy and tact as they may be facing lot of emotional difficulties which produce lot of unhappiness. History taking is extremely difficult in the elderly due to senility and deafness. It requires great patient and tactful handling. Do not get irritated by discourtesy.
What precautions should be taken during general examination, careful look at the manner of walking, standing and sitting of the patient, posture of the patient during examination, facial complexions have all been discussed in greater detail. Last chapter in the book gives some useful tables of differential diagnosis which the reader will again find quite useful. As stated by the author himself this book in no way is intended to replace the initial study of a text book or the detailed study of clinical methods for the understanding of different subjects.
Despite the fact that this book contains lot of useful information and could be extremely helpful not only for the busy practitioners but medical students and postgraduates alike, overall presentation leaves much to be desired. Title could still have been more attractive which makes all the difference. Not only that selection of type faces, use of boxes or summary at the end of each chapter to highlight the important take home messages would have made it still much more useful. However, as we know, to author a book in Pakistan is not an easy task and to publish a book is a very expensive hobby. Not many are interested in buying a book but would like to have a complimentary copy if possible, hence how to cover the cost of production. This must have been one of the reasons for an average presentation otherwise had it been published by some professional publishes, its presentation would have been much better but it would have also increased the cost of production manifold. The author has not failed to acknowledge the help and assistance of Maj. Gen.Badshah Hussain Zaidi. Price Rs. 500/- Available at Allied Book Company Naqi Market, 75 the Lower Mall Lahore and Pak Book Corporation Lahore, Islamabad and Karachi. E mail This email address is being protected from spambots. You need JavaScript enabled to view it. SAJ