How I Practice Medicine, Part 3: Sore throats and Swollen Glands| The Life of a Hotel Doctor | By Mike Oppenheim, M.D.

When you see a doctor in an office, someone takes your blood pressure. I do the same but rarely find it helpful. Blood pressure gives important information when you feel fine and when you’re seriously ill, but it’s not much use where you’re merely miserable. A normal pressure isn’t helpful, but if it’s abnormal, well… You’re miserable. Being miserable can make blood pressure fluctuate. Some doctors deal with an abnormal reading by assuring the patient it’s probably meaningless but suggest he see his doctor for a recheck later. That gives the patient something new to worry about.

Everyone who might have an infection needs a temperature. Until recently I used the most accurate instrument, an old fashioned thermometer, a device fast disappearing because they occasionally break, and mercury is bad for the environment. Digital thermometers are accurate, too, but someone must calibrate them now and then. They were once calibrated against the most accurate standard: a mercury thermometer. Digitals offer another advantage: speed. Used properly, an old-fashioned thermometer must remain in the mouth at least two minutes, something that didn’t happen when the aide was in a hurry or grew bored waiting. I solved this problem by filling out my encounter form. For common ailments, I completed it, including the results of the exam (all normal), the diagnosis, and my treatment. You’d be surprised how often the doctor knows the diagnosis as soon as you describe your symptoms. For respiratory infections, that approaches 100 percent, but now and then I crossed out my entries and made corrections.

It’s appropriate to examine whatever body part bothers the patient. I’m rarely in a hurry, so for respiratory infections my routine includes throat-neck-chest plus ears for children and anyone with symptoms. Every patient with a painful throat peers at it in a mirror and then expresses disbelief when I announce it looks normal. I explain that people rarely examine their throat when it feels fine; throats are normally red and tonsils bumpy. Almost everyone considers “white spots” on the tonsils an ominous sign, and this is as accurate as most popular heath beliefs. Plenty of minor viral infections produce spotty tonsils. Hearing this, patients invariably ask “Then how do I know I’m really sick?” I give the same answer I’ve given thousands of times, and you’ll probably read it a few times here: “Sickness makes you sick. See a doctor if you feel sick. If you don’t feel very sick, you’re probably not sick.” For otherwise healthy people with minor illnesses, this is an excellent rule. No rule is absolute, and this one has exceptions but it’s vastly superior to all other popular rules (“See a doctor if you have a fever…” “See a doctor if your sputum turns green…” “See a doctor if you notice spots on your tonsils…”).

I feel the neck for enlarged lymph nodes and sometimes find them. Patients worry when they discover a swollen node, so I explain that this is rarely a serious matter. The lymph node swells because lymphocytes are crowding in to fight the infection, and pain is the result of stretching the node’s wall. The node is doing what it was designed to do.

I’ll write about my heart and lung exam in the next column.