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June 18, 2020

Grasping What We Cannot Touch: Examining the Telemedicine Patient

Author Affiliations
  • 1Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana
JAMA Otolaryngol Head Neck Surg. 2020;146(8):685-686. doi:10.1001/jamaoto.2020.1266
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    1 Comment for this article
    An Inter-disciplinary Approach to Detection of Severe Systemic Pathology in Telemedicine Consultations
    Peter Shah, BSc MA FRCOphth FRCP Edin | University Hospitals Birmingham NHS Foundation Trust
    In 'Grasping What We Cannot Touch' Edward McCoul elegantly describes a wealth of clinical information that can be gleaned from a remote ENT consultation.

    To his list, I would add certain signs that may help to exclude severe systemic / life-threatening pathology.

    [1] Ophthalmic examination: In addition to the features described I would add:

    - Ptosis and anisocoria (Third nerve palsy and Horner's syndrome).
    - Abnormal eye position in primary gaze (Third / Sixth nerve palsy).
    - Fatigue of extraocular movements / ptosis (Myasthenia gravis).
    - Eyelid margins and skin (BCC / SCC / Malignant melanoma). /> - Nystagmus (Brainstem / cerebellar pathology).
    - Conjunctival injection + proptosis (Dural venous fistula / Cavernous sinus thrombosis / thyrotoxicosis).
    - Conjunctiva - jaundice and severe anaemia.
    - Enophthalmos - Malignant / traumatic sinus / nasopharyngeal disease / orbital disease.

    [2] Examination of the hands and nails:

    - Clubbing (Malignancy / Pumonary / Cardiac disease).
    - Splinter haemorrhages (Bacterial endocarditis / scleroderma).
    - Leukonychia striata (Hypoalbuminaemia / Nephrotic syndrome).
    - Beau's transverse ridges (Severe infection / Malnutrition).
    - Lindsay's nail pigment deposition (Severe renal disease).
    - Tremor (Neurological / Hepatic / Endocrine disease).

    [3] Height / Weight / BMI (Idiopathic intracranial hypertension / Diabetic ketoacidosis / Malignancy).

    By sharing inter-disciplinary clinical pearls, we can increase the pick-up rate of severe regional and systemic problems in telemedicine consultations.