The Physical Exam Can Be Pretty Important, Part 2
I was participating in morning rounds with a team of internal medicine residents. That day was the beginning of a rotation change, and a new “house attending” (the doctor in charge of the inpatients who had no primary care physician) was getting to know his patients. The residents who had been caring for the patients took turns explaining (near the bedsides) what had gone on since their admissions to the hospital, and described their treatment plans.
One intern presented a case of a patient with “fever of unknown origin” (FUO). This particular diagnosis will make any internal medicine specialist delirious with curiosity and excitement, since it means that all the previous attempts at discerning the cause of the patients fever have failed. Generally, a fever only receives this exciting honor when it has gone on for at least 3 weeks without apparent cause.
The intern explained (in excruciating detail I might add) every single potential cause of the fever and how he had ruled them out with tests and deductive reasoning. The attending was hanging on every word, and nodding in approval of some real zebras (rare and highly unlikely causes for the fever) that the intern had thought to consider and disprove.
I must admit that my mind wandered a bit during this long exercise, and instead I looked at the patient, smiled, and examined his thick frame with my eyes. Of course, an attending has a keen sense for wandering minds, and so to “teach me a lesson” he abruptly stopped the intern’s presentation and looked me dead in the eye. You could have heard a pin drop.
“So, Dr. Jones” he snarled. “You seem to have this all sorted out, don’t you. Apparently you have determined the diagnosis?”
“Well, yes, I think I may have.” I replied calmly.
The attending’s face turned a slightly brighter pink. “Well, then, don’t withhold your brilliance from us any longer. You’re a rehab resident, are you not?” He made a dismissive move with his right hand and rolled his eyes.
“Yes, I am.” (Snickers from the internal medicine residents.) I shot a glance at them that shut them up.
I continued, “Well, Dr. ‘Attending,’ as the intern was reviewing the potential causes of FUO, I took a look at the patient. It seems that there is a pus stain on the bottom of his right sock. I didn’t hear the intern describe the patient’s foot exam.”
The intern’s face went white as a sheet.
The attending turned to the intern with an expression of betrayal. “Did you examine this patient’s feet?”
“Well I uh… well, no.” Stammered the intern. “I guess I forgot to remove his socks.”
The attending marched over to the bedside and quickly removed the patient’s right sock, a small snow storm of dried skin flakes fell gently to the hospital floor. A festering foot ulcer proudly displayed itself to the team.
The attending gingerly nodded at me. He turned to the intern and announced that he would be given an extra night of call this month so that he’d have time to examine his patients’ bodies from head to TOE.
The patient was treated with antibiotics and sent home.
The intern later went on to become a radiologist.
I am working on improving patient empowerment on a national basis through Revolution Health.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
It must be so cool to be in a discipline where you can use terms like “festering foot ulcer”. I have worked with people who I should have called something like that.
What a great story Dr. Val! And kudos to you
Go Dr. Val!!
This is a nice story. As a lesson that will surely be very useful in the future, I have to remember this.