Medical sign

A medical sign is an objective[1] indication of some medical fact or characteristic that may be detected and still or video photographed or audio-recorded by a patient or anyone, especially a physician, before or during a physical examination of a patient. For example, whereas a tingling paresthesia is a symptom (only the person experiencing it can directly observe their own tingling feeling), erythema is a sign (anyone can confirm that the skin is redder than usual). Symptoms and signs are often nonspecific, but often combinations of them are at least suggestive of certain diagnoses, helping to narrow down what may be wrong. In other cases they are specific even to the point of being pathognomonic.

Some signs may have no meaning to the patient, and may even go unnoticed, but may be meaningful and significant to the healthcare provider in assisting diagnosis.

Examples of signs include elevated blood pressure, a clubbing of the ends of fingers (which may be a sign of lung disease, or many other things), a staggering gait (human) and arcus senilis of the eyes.

The term sign is not to be confused with the term indication, which denotes a valid reason for using some treatment.

Signs and semiotics

The art of interpreting clinical signs was originally called semiotics (a term now used for the study of sign communication in general) in English. This term, then written semeiotics (derived from the Greek adjective σημειωτικός: semeiotikos, "to do with signs"), was first used in English in 1670 by Henry Stubbes (1631–1676), to denote the branch of medical science relating to the interpretation of signs:

…nor is there any thing to be relied upon in Physick, but an exact knowledge of medicinal phisiology (founded on observation, not principles), semeiotics, method of curing, and tried (not excogitated, not commanding) medicines….[2]

Signs versus symptoms

Signs are different from symptoms, the subjective experiences, such as fatigue, that patients might report to their examining physician.

For convenience, signs are commonly distinguished from symptoms as follows: Both are something abnormal, relevant to a potential medical condition, but a symptom is experienced and reported by the patient, while a sign is discovered by the physician during examination or by a clinical scientist by means of an in vivo examination of the patient.[3]:75

A slightly different definition views signs as any indication of a medical condition that can be objectively observed (i.e., by someone other than the patient), whereas a symptom is merely any manifestation of a condition that is apparent to the patient (i.e., something consciously affecting the patient). From this definition, it can be said that an asymptomatic patient is uninhibited by disease. However, a doctor may discover the sign hypertension in an asymptomatic patient, who does not experience "dis-ease", and the sign indicates a disease state that poses a hazard to the patient. With this set of definitions, there is some overlap – certain things may qualify as both a sign and a symptom (e.g., a bloody nose).

Lester S. King, author of Medical Thinking, argues that an "essential feature" of a sign is that there is both a sign [or "signifier"] and a "thing signified". And, because "the essence of a sign is to convey information", it can only be a sign, properly speaking, if it has meaning. Therefore, "a sign ceases to be a sign when you cannot read it".[3]:73–74 A person, who has and exercises the knowledge required to understand the significance or indication or meaning of the sign, is necessary for something to be a complete sign. A physical phenomenon that is not actually interpreted as a sign pointing to something else is, in medicine, merely a symptom. Thus, King rejects "these present-day views [distinguishing signs from symptoms based on patient-subjective versus clinician-objective], however widely accepted, as quite faulty, at variance not only with ordinary usage but with the entire history of medicine."[3]:77

"[A] symptom is a phenomenon, caused by an illness and observable directly in experience. We may speak of it as a manifestation of illness. When the observer reflects on that phenomenon and uses it as a base for further inferences, then that symptom is transformed into a sign. As a sign it points beyond itself — perhaps to the present illness, or to the past or to the future. That to which a sign points is part of its meaning, which may be rich and complex, or scanty, or any gradation in between. In medicine, then, a sign is thus a phenomenon from which we may get a message, a message that tells us something about the patient or the disease. A phenomenon or observation that does not convey a message is not a sign. The distinction between signs and symptom rests on the meaning, and this is not perceived but inferred."[3]:81

Types of signs

Medical signs may be classified by the type of inference that may be made from their presence, for example:

"[If the patient's facial] appearance may be described thus: the nose sharp, the eyes sunken, the temples fallen in, the ears cold and drawn in and their lobes distorted, the skin of the face hard, stretched and dry, and the colour of the face pale or dusky.… and if there is no improvement within [a prescribed period of time], it must be realized that this sign portends death."[4]
"Symptoms become signs when they permit inference. Ordinarily, one single symptom by itself — such as pain or swelling, or discoloration, or bloody discharge — would not permit any specific inference, but when symptoms occur in clusters and form a pattern, then the aggregate might point to a particular disease. The pathognomonic sign, however, does not need any other manifestation to lead the physician to the correct diagnosis. It constitutes a one-to-one relationship — the sign and the disease are uniquely related. The pathognomonic sign was the "clincher", the datum that established the diagnosis unequivocally."[3]:100

Technological development creating signs detectable only by physicians

Prior to the nineteenth century there was little difference in the powers of observation between physician and patient. Most medical practice was conducted as a joint co-operative interaction between the physician and his aristocratic patient as equals; this was gradually replaced by a "monolithic consensus of opinion imposed from within the community of medical investigators".[5][6] Whilst each noticed much the same things, the physician had a more informed interpretation of those things: "the physicians knew what the findings meant and the layman did not".[3]:82

Advances in the 19th century

However, the patient was gradually removed from the medical interaction[5][6][7] due to significant technological advances such as:

Alteration of the relationship between physician and patient

The introduction of the techniques of percussion and auscultation into medical practice altered the relationship between physician and patient in a very significant way, specifically because these techniques relied almost entirely upon the physician listening to the sounds of the patient's body.

Not only did this development greatly reduce the patient's capacity to observe and contribute to the process of diagnosis, it also meant that the patient was often instructed to stop talking, and remain silent.

As these sorts of evolutionary changes continued to take place in medical practice, it was increasingly necessary to uniquely identify data that was accessible only to the physician, and to be able to differentiate those observations from others that were also available to the patient, and it just seemed natural to use "signs" for the class of physician-specific data, and "symptoms" for the class of observations available to the patient.

King proposes a more advanced notion; namely, that a sign is something that has meaning, regardless of whether it is observed by the physician or reported by the patient:

The belief that a symptom is a subjective report of the patient, while a sign is something that the physician elicits, is a 20th-century product that contravenes the usage of two thousand years of medicine. In practice, now as always, the physician makes his judgments from the information that he gathers. The modern usage of signs and symptoms emphasizes merely the source of the information, which is not really too important. Far more important is the use that the information serves. If the data, however derived, lead to some inferences and go beyond themselves, those data are signs. If, however, the data remain as mere observations without interpretation, they are symptoms, regardless of their source. Symptoms become signs when they lead to an interpretation. The distinction between information and inference underlies all medical thinking and should be preserved.[3]:89

Signs as tests

In some senses, the process of diagnosis is always a matter of assessing the likelihood that a given condition is present in the patient. In a patient who presents with haemoptysis (coughing up blood), the haemoptysis is very much more likely to be caused by respiratory disease than by the patient having broken their toe. Each question in the history taking allows the medical practitioner to narrow down their view of the cause of the symptom, testing and building up their hypotheses as they go along.

Examination, which is essentially looking for clinical signs, allows the medical practitioner to see if there is evidence in the patient's body to support their hypotheses about the disease that might be present.

A patient who has given a good story to support a diagnosis of tuberculosis might be found, on examination, to show signs that lead the practitioner away from that diagnosis and more towards sarcoidosis, for example. Examination for signs tests the practitioner's hypotheses, and each time a sign is found that supports a given diagnosis, that diagnosis becomes more likely.

Special tests (blood tests, radiology, scans, a biopsy, etc.) also allow a hypothesis to be tested. These special tests are also said to show signs in a clinical sense. Again, a test can be considered pathognonomic for a given disease, but in that case the test is generally said to be "diagnostic" of that disease rather than pathognonomic. An example would be a history of a fall from a height, followed by a lot of pain in the leg. The signs (a swollen, tender, distorted lower leg) are only very strongly suggestive of a fracture; it might not actually be broken, and even if it is, the particular kind of fracture and its degree of dislocation need to be known, so the practitioner orders an x-ray — and, for example, if the x-ray were to show a fractured tibia, the film would be diagnostic of the fracture.

Examples of signs

See also

References

  1. ↑ "Definition: 'Sign'". Stedman's Medical Dictionary. Lippincott Williams & Wilkins via Medilexicon International Ltd.'s website, medilexicon.org. Retrieved 12 December 2013.
  2. ↑ Stubbe, H. (Henry Stubbes), The Plus Ultra reduced to a Non Plus: Or, A Specimen of some Animadversions upon the Plus Ultra of Mr. Glanvill, wherein sundry Errors of some Virtuosi are discovered, the Credit of the Aristotelians in part Re-advanced; and Enquiries made... (London), 1670, p. 75
  3. 1 2 3 4 5 6 7 8 9 10 11 12 King, Lester S. (1982). Medical Thinking: A Historical Preface. Princeton, NJ: Princeton University Press. ISBN 0-691-08297-9.
  4. ↑ Chadwick, J. & Mann, W.N.(trans.) (1978). Hippocratic writings. Harmondsworth, UK: Penguin. pp. 170–171. ISBN 0-14-044451-3.
  5. 1 2 Jewson, N. D., "Medical Knowledge and the Patronage System in 18th Century England", Sociology, Vol.8, No.3, (1974), pp. 369–385.
  6. 1 2 Jewson, N. D., "The Disappearance of the Sick Man from Medical Cosmology, 1770–1870", Sociology, Vol.10, No.2, (1976), pp. 225–244.
  7. ↑ Tsouyopoulos N (1988). "The mind-body problem in medicine (the crisis of medical anthropology and its historical preconditions)". Hist Philos Life Sci. 10 Suppl: 55–74. PMID 3413276.
  8. ↑ Weatherall, D. (1996). Science and the Quiet Art: The Role of Medical Research in Health Care. New York: W. W. Norton & Company. p. 46. ISBN 0-393-31564-9.
  9. ↑ Allbutt, T.C., "Medical Thermometry", British and Foreign Medico-Chirurgical Review, Vol.45, No.90, (April 1870), pp.429-441; Vo.46, No.91, (July 1870), pp.144-156.

External links

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