An Old-Fashioned Diagnostic Technique

Today’s New York Times Sunday Magazine (February 25, 2007) carries the case study of a 23-year-old teacher who developed a massive blood clot in the lung (pulmonary embolism) that landed him in the ICU for several days. Although his physicians were able to make the diagnosis easily through the use of scans, the source of the clot eluded them.

At some point the patient consulted Dr. Thomas Duffy, a sixty-something hematologist at Yale University School of Medicine known for his diagnostic abilities. Dr. Duffy asked the patient to perform a simple maneuver with his arm that pointed him to the correct diagnosis of thoracic outlet syndrome, the condition that led to the source of the clot.

Dr. Lisa Sanders, the internist who writes these periodic columns for the New York Times Sunday Magazine, admits that she “had never heard of the old-fashioned arm maneuver. This and other physical-exam techniques,” she writes, “are part of a disappearing tradition in medicine—replaced more or (in this case) less successfully with a variety of high-tech imaging techniques.”

Dr. Sanders comments: “Had a doctor not done this simple test, the patient’s abnormality may not have been picked up, and he would have been stuck taking medicine he didn’t need (for the rest of his life) and missing out on the sports he loved.”

It is indeed sad commentary that our medical education system no longer emphasizes such techniques in physical diagnosis. Instead, physicians-in-training are taught to rely on more sophisticated imaging and laboratory studies—always considerably more expensive and not necessarily productive.

Thirty years ago, as a Physician Assistant student at Hahnemann Medical College and Hospital, I remember being taught the maneuver Dr. Duffy employed with this patient in my physical diagnosis class. I consulted my copy of Methods of Clinical Examination: A Physiologic Approach (Judge and Zuidema. Boston: Little, Brown and Company, 3rd Ed., 1974), where a description of the Adson maneuver appears on page 292:

“Palpate the radial pulse on the side to be tested. Instruct the patient to extend the neck and turn the chin to the side to be tested. The transient disappearance of the radial pulse during inspiration signifies temporary occlusion of the subclavian artery as the anterior scalene muscle is tensed (by extension of the neck and rotation of the skull) while the ‘floor’ of the thoracic outlet rises during inspiration.…These signs may be intensified as the shoulder is abducted and externally rotated.”

I was gratified to find that in my book I had underlined the text.

In their preface, authors Richard Judge, M.D., and George Zuidema, M.D., note that “the practicing physician may find a few pearls buried within these pages; for the art of medicine is seldom if ever mastered, even by the expert.”

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