Friday, March 18, 2011
The value of at least one patient's physical exam
I've remarked in the past how rarely I ever learn anything useful from physical exam. It's one of those irritating things about medicine. We spent all that time in school learning arcane details of the exam, esoteric maneuvers like pulsus paradoxus, comparing pulses, Rovsing's sign and the like. But in the modern era, it seems like about half the diagnoses are made by history and the other half are made by ancillary testing. Some people interpreted my comments to mean I don't do an exam, or endorse a half-assed exam, which I do not. I always do an exam, as indicated by the presenting condition. I just don't often learn much from it. But I always do it.
The other day, for example, I saw this elderly lady who was sent in for altered mental status. There wasn't much (or indeed, any) history available. She was from some sort of nursing home, and they sent in essentially no information beyond a med list. The patient was non-verbal, but it wasn't clear if she was chronically demented and non-verbal or whether this was a drastic change in baseline. So I went in to see her. I stopped at the doorway. "Uh-oh. She don't look so good," I commented to a nurse. As an aside, this "She don't look so good" is maybe 90% of my job, the reflexive assessment of sick/not sick, which I suppose is itself a component of physical exam. But I digress. Her vitals were OK, other than some tachycardia*. Her color, flaccidity and apathy, however, really all screamed "sick" to me. Of course, the exam was otherwise nonfocal. Groans to pain, withdraws but does not localize or follow instructions. Seems symmetric on motor exam, from what I can elicit. Belly soft, lungs clear. Looks dry. No rash.
Sigh. Probably another case of urosepsis. Sorry, I mean UTI with sepsis. Boring, and unsatisfying. Let's scan her and cath her and lab her and see what shows up. Let me just take a look at her legs and make sure there's no cellulitis or anything there. Nope, but boy she really groaned when I moved that leg, didn't she? Weird. Seems that left hip hurts her when I push on it. Did she fall out of bed? Maybe she's got a broken hip. Is there a bump on her head? That would explain the altered mental status. Nope. So I flip up her gown to look at the hip better, and I was surprised to see a bright red rash all around her leg and pannus (she was quite large). Huh. Here we go, she has a rip-roaring cellulitis. That would explain the altered mental status quite nicely. Good. I'd better take a look at her backside, though. She might have a pressure sore there that could be the source, and we have to document that it was present on admission. The nurses glared at me a bit, but we got a team together and rolled her on her side so I could examine her sacrum. No pressure ulcer, and I was about to let them roll her back, when I noticed something. "Hey, what's that?"
It was a little dark area, like a bruise, just the size of a quarter, on the back of her thigh. But it wasn't quite like a bruise. It was too sharply demarcated, and too dark, almost black. I poked at it, but she didn't groan, and the skin was intact. Weird. It was involved in the cellulitic area, though.
I didn't like it. So as I put in the orders I decided to add on a CT scan. Shortly afterwards, the labs started to come back, and it was clear this was looking serious. White count of 22,000. Glucose 950. Creatinine 3.5. All bad. Then the call from the radiologist**. I pulled up the images:
There was extensive air all through the soft tissues of the thigh, tracking to the perineum and the abdominal wall. Aha! Now this made perfect sense. She had necrotizing fasciitis, commonly known as the "flesh eating bacteria!" This is a true surgical emergency, and indeed she got a very big surgery. The whole area involved simply had to be excised, and in such a sick patient, that's a huge operation, with a very high mortality. When the family eventually showed up, I prepared them with the "She may very well not survive" talk. (And, yes, it turned out this was a dramatic change from her baseline level of function.) To everyone's great surprise, she did pull through the surgery (and the repeat surgeries), and last I saw was getting prepped for discharge to rehab.
The take home point here, really, was that the physical exam, while a rote and generally unrevealing exercise, simply cannot be skipped. This lady had no crepitance, the crackling underneath the skin that is classically the hallmark of subcutaneous gas. I think she was just too fat, and the thigh too tense, and maybe the air too widely disseminated. If I had not taken the time to look at her backside, I would never have seen the black spot that clued me into the fact that this was more than a routine cellulitis. Had I sent her to the floor on antibiotics, she would have died. This is not at all to be taken as a recantation of my original thesis. In 99% of cases, I learn little to nothing from the exam. She just happened to be in the 1% that actually had a critical finding, which proves the corollary to my thesis, that despite the seeming pointlessness of exam, you still have to do it.
* Pro tip #1 for Emergency Medicine interns: Respect tachycardia.
** Pro tip #2: The radiologist never calls to discuss the fortunes of your local sports team, or a pleasant surprise he experienced in the market. It's always something bad when the radiologist deigns to speak directly to the emergency physician.
This post by Liam Yore, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
Contact ACP Internist
Send comments to ACP Internist staff at firstname.lastname@example.org.
- Should doctors treat asymptomatic strep throat?
- Doctors choose Camel cigarettes in an old TV comme...
- QD: News Every Day--Death rate tapers for tenth st...
- QD: News Every Day--Academics see slightly higher ...
- QD: News Every Day--MedPAC recommends primary care...
- QD: News Every Day--Most states aren't prepared fo...
- Do women need an annual pelvic exam?
- QD: News Every Day--Massachusetts residents satisf...
- Thank you for not smoking redux
- QD: News Every Day--Obesity trumps adiposity for c...
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.