Clinical paradox. Man versus machine.

I the present era of technological advancement, the clinicians have to rely on investigations in addition to their clinical skills to make an appropriate diagnosis. However, it is still far from practical that machines take over and replace the clinical skills completely. We would like to present a few clinical scenarios illustrating the role of machine and man in making a clinical diagnosis. Machine versus man. Heart murmurs are not infrequent in the early newborn period. Fortunately, most of the murmurs are due to the closing ductus or non-structural heart problems. However, a murmur could be an early manifestation of congenital heart disease. In that scenario, using echocardiogram (ECHO) may be essential to delineate the exact anatomy of the heart. Even expert clinical cardiologists rely on that. One might try repeated cardiac auscultation, 4 limb blood pressure (4-limb BP) measurements, electrocardiogram (ECG) or chest x-ray (CXR), however, the sensitivity and specifi city of these investigations have been questioned.1-4 Thus, in a center where ECHO facilities are available readily, the reliance on only clinical examination may be dangerous and time should not be wasted in getting the 4-limb BP, ECG and CXR murmur. A direct ECHO approach seems to be a better alternative. In this example we saw how technology takes over the clinical skills. Now we will look at the other example where reliance on laboratory parameters may be deceptive, while clinical expertise reaches the diagnosis. Man versus machine. Patient 1. A term small for gestational age baby on day 6 of life presented to accident and emergency (A&E) with poor feeding and lethargy. This baby was discharged one day prior from the postnatal ward in healthy condition. The immediate postnatal course was complicated by polycythemia and hyperbilirubinemia treated with partial exchange transfusion and phototherapy. The baby remained stable tolerating ad lib breast feedings and the discharge examination was unremarkable. The antenatal and perinatal history was unremarkable. Motherʼs serology tests for HIV, syphilis and hepatitis were negative. The high vaginal swab showed normal fl ora. On presentation to A&E, the baby was noted to be hypoactive and thus, after initial stabilization was immediately transferred to the special care baby unit (SCBU) for further management. In the SCBU, a septic work up was carried out and the baby was started on antibiotics. The white cell count (WBC) was unremarkable (Table 1). Six hours later, the baby threw a convulsion, which was controlled by intravenous phenobarbitone. Microscopy of spinal fl uid showed group B streptococcus. The baby was treated with a meningitic dose of penicillin and he responded well. The baby was discharged home after discontinuing the anticonvulsants, and completing the full 21-day course of antibiotics. A follow up in a high-risk neonatal clinic is planned. Patient 2. A preterm small for gestational age baby who had uneventful postnatal course, on day 14 of life was noted to have frequent desaturations. Examination revealed a temperature of 38.50C with poor activity. The anterior fontanelle felt full but was Brief Communication