To the Editor:
The death of “Mr. Abbott” (*) whose overlooked aortic dissection was misdiagnosed as an acute coronary syndrome, illuminates more than just the demise of the physical examination. It also illustrates Goethe’s precept “What one knows, one sees” (1).
A patient writhing because of chest pain should immediately be suspected to have aortic dissection (2)(3). Patients with chest discomfort due to coronary events more characteristically lie motionless (3), as noted in older (4), but not newer (5) cardiology textbooks.
Today’s highly specific imaging and biochemical tests have changed the role of physical examination from hypothesis confirmation to hypothesis generation. However, these tests have not, in the words of Dr. Joseph Bell (the model for Sherlock Holmes), changed the obligation of each physician to know “the features of disease… as precisely as you know the features, the gait, the tricks of manner of your most intimate friend” (3).
(*) Jauhar S. The demise of the physical exam. N Engl J Med. 2006; 354: 548-551.
(1) DeGowin RL. DeGowin & DeGowin's Bedside Diagnostic Examination. 5th ed. New York: Macmillan, 1987; 37.
(2) Slater EE. Aortic dissection: presentation and diagnosis. In: Doroghazi RM, Slater EE, Aortic Dissection. New York: McGraw-Hill, 1983; 62.
(3) Sotos JG. Zebra Cards. Philadelphia: American College of Physicians, 1989; page 19 and card HE-011.
(4) Pasternak RC, Braunwald E, Sobel BE. Acute myocardial infarction. In: Heart Disease. 3rd ed. Braunwald E (ed.). Philadelphia: WB Saunders, 1988; 1235.
(5) Antman EM, Braunwald E. Acute myocardial infarction. In: Heart Disease. 5th ed. Braunwald E (ed.). Philadelphia: WB Saunders, 1997; 1198.