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A Surprising Discovery And The Value Of The 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:

necfasc3

necfasc2

necfasc
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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 famliy 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 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 Somethign Bad when the radiologst deigns to speak directly to the emergency physician.

*This blog post was originally published at Movin' Meat*


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