Model Patient

Ask the DOC

I have written previously about the need for keen powers of observation in the field of medicine. I referred to Sherlock Holmes and his creator, the physician Arthur Conan Doyle. There have always been battles in medicine between those who advocate for observation and those who favor textbooks and learning. Oliver Wendell Holmes Sr., who was a professor of medicine at Harvard Medical School, once wrote, “Let a student have illustrations, and just so surely he will use them at the expense of the text.” The illustrations he was referring to were in Gray’s Anatomy. To become a physician, one must read and memorize lots of written text but must also balance that with illustrations.

The picture in today’s column was drawn by Frank Netter in the 1970s. He was a famous medical illustrator and did most of the illustrations for Grant’s Anatomy, the textbook I used in medical school (it’s still on my office shelf). It’s called The Pink Puffer. Close examination of it will reveal much detail, including the patient’s disease. Note how he is sitting, with his elbows on the armrests in what’s called a tripod position. Note the muscle wasting and loss. By putting his elbows on the armrests, or knees if there were no armrests, he is elevating his shoulders and clavicles. This is called the thinker’s sign. It allows him to breath using his pectoralis muscles, rib muscles, and clavicular muscles, also known as using accessory respiratory muscles. Also note the pursed lips. By exhaling through pursed lips, he elevates his respiratory pressure, allowing him to breathe more easily and lower his carbon dioxide levels. This patient has severe chronic obstructive pulmonary disease, otherwise known as COPD or emphysema, most likely from smoking.

One detail that is not in the picture is clubbing. Clubbing is widening and flattening of the fingernails and fingertips which occurs in response to lower oxygen levels and higher carbon dioxide levels. But Netter was correct in this omission because clubbing is rare in COPD but common in chronic bronchitis. Those with chronic bronchitis are often referred to as blue bloaters, which this patient clearly is not. As they say, a picture is worth a thousand words, or to again quote Yogi Berra: “You can observe a lot by watching.”


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