A Word on Melanoma Awareness
If your school’s physical diagnosis class teaches you how to perform a physical exam at all like how I learned at my school, then the phrase “inspection, palpation, percussion, and auscultation” probably gives you horrifying flashbacks of cramming prior to your clinical skills exams during your pre-clerkship years. In fact, you might have even said something like “I am now inspecting your chest for any asymmetry now” at some point while examining a standardized patient because you were paranoid that the graders might take off points for skipping inspection. The reality is that these four principles of inspection, palpation, percussion, and auscultation are pounded into our heads for good reason, it can be easy to miss things when there is no organization to a physical exam. Unfortunately, I have the perfect example of what exactly can happen when the first principle step of the physical exam is overlooked.
I am on my internal medicine rotation during third year when I get assigned to go see 50-year-old man in the ED who is going to be admitted, it sounds like he has pneumonia. I am the first to see the patient and he lets me know that he has been hospitalized a couple of times for his cough and shortness of breath in the last couple months at multiple hospitals. His records showed that he had received multiple courses of antibiotics, but never fully recovered, and that he seems to have this persistent infiltrate on the left lung. It was an interesting case. An obscure multi-drug resistant bug was eventually identified as the culprit, but the most striking aspect of the case had nothing to do with the patient’s chief complaint. When I opened the patient’s gown for inspection of his back prior to auscultating I spotted an ominous lesion. The lesion was a pigmented, two by three centimeter ovoid patch with irregular borders, considerable asymmetry and significant intralesional color variation. This lesion violated all the ABCD’s and probably belonged in a pathology textbook under the heading “superficial spreading melanoma.” I brought it to the man’s attention; he had never noticed it on his back and no one had ever mentioned it to him before.
In the story that I shared with you above, a man left the hospital knowing that he had melanoma when he came in for something totally unrelated. Rightfully so, this man was shocked to hear that he had melanoma, but he was even more dismayed when he realized that it was likely missed at the other hospitals. Now I share this story with you not to cast blame, unfortunately mistakes happen every day, this is why quality improvement has become such a huge area of research in medicine. I also do not aim to boast about my physical diagnosis skills; in fact, it was likely my inexperience which forced me to strictly follow the four principles of physical exam and find the lesion to begin with. I do, however, want to highlight the importance of melanoma awareness among us, the future medical professionals. We often promote disease awareness as an important trait to have as a patient, but it is a trait that is important for clinicians as well. If shortcuts are taken during the physical exam and we simply look instead of critically inspect, then we are doing our patients a disservice and are, therefore, unaware.
Melanoma Awareness Chair