One of the difficult things about learning the art of the physical exam early in medical school is learning to differentiate pathology from normal. I remember when we first were instructed on the lung exam. We learned about these ambiguous terms... rales, rhonchi, egophony, stridor, tactile fremitus. I learned that you could have crackles in your lungs, and set about listening to the lungs on all my patients very closely. And I discovered a funny thing. Vesicular (aka normal) breath sounds can sound kinda-crackley if you listen close enough. All my patients started having crackles. I asked a doc I was working with one day "What do crackles sound like? Because it sounds to me like all my damn patients have crackles."
Eventually, I had a patient with real crackles, and like anything else with the physical exam, once you listen and touch enough normal patients the pathology begins to jump out at you. But this story isn't about that patient. It's about a patient I saw earlier this week, a 65 year old man with chronic kidney disease and congestive heart failure who presented with shortness of breath. He was actually my
first patient I've seen with 3+ pitting edema, I damn near lost the entirety of my index finger into his left shin. But this story is about crackles, and I noticed a certain quality to his voice as I was talking to him in the exam room. No hoarseness or changes in phonation. But it sounded like someone had just poured themselves a bowl of rice krispies and set it in the corner. The snap, crackle, pop became more audible with each labored breath he took. For some reason, the moment brought me back to my early days of listening to the lungs, waiting for total silence and listening intently, hoping to catch a crackle or two in passing. And here I had a patient sitting in front of me with so much fluid brimming out of his lungs that I didn't even have to place a stethoscope on him to hear the crackles.
Sadly, in this economy, I'm not sure Kelloggs is looking for any new spokespersons anytime soon.
So I was in clinic the other day, and the next two patients on the schedule looked like this:
10:45am - 21 yo male - abdominal pain
11:00am - 28 yo female - abdominal pain
Hrmmm... which one of these is the appendicitis? The doc I'm working with decides to leave it up to a coin flip on which one I see and which one he sees. Heads, I get the 21 yo dude. Tails, the 28 yo dudette.
Heads.
Cool, 21 year old guy with new onset abdominal pain is about 'classic' for appendicitis as you get. I knock, enter the room, and the exchange does something like this (abridged for everyone's sake):
Nice to meet you, Mr. Abdominal Pain Dude, tell me what's going on.
"My stomach's hurting."
How long has it been hurting?
"Oh a while."
A while as in several days? Several weeks? Months?
"It started at 9 pm last Tuesday, I was sitting on the couch eating french fries and watching Biggest Loser."
...I could see in a hurry that this conversation was hurtling out of control into the "awkward patient encounters" category...
Can you point to where it hurts?
*points to RUQ*
Does it hurt anywhere else?
"My back hurts all the time, and spine pain. And my jaw has been hurting recently. Is that related? I also have nerve sensitivity, like if you touch me here, it hurts. See? That hurts. So don't touch me."
Any nausea or vomiting?
"Well I just throw up sometimes. So I don't know."
Hrmmm, interesting. Have you thrown up since this pain started?
"Oh yeah. In fact, I think I could throw up on your face right now."
Any change in your stool? Diarrhea or constipation?
"I always have diarrhea."
Also interesting. Any other symptoms?
...I see the patient take a deep breath in preparation to respond. This is not a good sign...
"My neck hurts, and my hips hurt when I walk. Is that related? And can I get injections today? My anxiety is really bad recently and I'm out of xanax, can I get a refill? My therapist says I need a refill. I'm also out of my vicodin. I've had a fever of 98.9 all week, and I feel really sweaty. I lost weight but then gained it back. I have to get up to pee sometimes at night but I think thats all the water I drink right before bed. My grandpa had colon cancer... oh my god is this colon cancer? I'm also pretty sure I have fibromyalgia. But that doesn't cause stomach pain, right? Could this be herpes? I'm pretty sure I have herpes. I've been tested 6 times and they were all negative but could this be it? I read on google once that herpes can attack your liver. But I'm pretty sure this is gallstones. Can I get them taken out?"
Long story short, I had no clue what to say after that, and felt that asking too many questions more would just further convolute the picture. Physical exam (yes, he ended up letting me touch him) was very benign, with maybe some very mild tenderness to palpation in the RUQ. We ordered up a chem10 (because, hey, he was right, herpesvirus can cause a fulminant hepatitis, despite the fact that he was not bright yellow) which showed a mild bump in alk phos and total bili. RUQ ultrasound found some very small gallstones. Whether they were the etiology of his abdominal pain or an incidental finding, who knows. He left with a GI referral. But no xanax refill.
Oh, and the 28 yo woman at 11:00 ended up having classic appendicitis.
first patient I've seen with 3+ pitting edema, I damn near lost the entirety of my index finger into his left shin. But this story is about crackles, and I noticed a certain quality to his voice as I was talking to him in the exam room. No hoarseness or changes in phonation. But it sounded like someone had just poured themselves a bowl of rice krispies and set it in the corner. The snap, crackle, pop became more audible with each labored breath he took. For some reason, the moment brought me back to my early days of listening to the lungs, waiting for total silence and listening intently, hoping to catch a crackle or two in passing. And here I had a patient sitting in front of me with so much fluid brimming out of his lungs that I didn't even have to place a stethoscope on him to hear the crackles.