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Inside Story
February 18, 2019

The “Hemolyzed” Physical Examination—Situational Challenges to Accurate Bedside Diagnosis

Author Affiliations
  • 1Department of Medicine, Baylor College of Medicine, Houston, Texas
JAMA Intern Med. 2019;179(4):465-466. doi:10.1001/jamainternmed.2018.8753

A page comes in from downstairs—another admission. A 41-year-old postal worker in bed 22, presented with severe back pain and needs pain control and a physical therapy evaluation. Three weeks ago, he was lifting a box when he felt a sharp pain in the middle of his lower back. The pain has not decreased, despite his taking naproxen around the clock. I look at the vital signs: temperature, 99°; pulse, 92 bpm; pressure, 140/90 mm Hg; respirations and oxygen saturation, normal. Nothing stands out as I click through the laboratory results.

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3 Comments for this article
David Mittman |
I have to say that intention and being present when you do an exam will make all the difference in the world. Maybe I'm old fashioned, but out of the last 10 exams I have had, no one palpated my abdomen, let alone percussed my lungs.
Have we given up a good physical just to get thousands of dollars of tests?
It seems so.
Dave Mittman, PA
Do you mean that PEs actually ARE important??
John Aldis, MD, MPH&TM | Private Practice
I am lucky to have had Drs. Ralph Major and Mahlon Delp (at the University of Kansas) teach me the value of the physical exam. We all resisted to some degree because of the excellent technology that was becoming available -- over fifty years ago. But they persisted, and we learned in spite of our "modern" attitudes.
It seems my profession needs to begin to deal with the reality that these physicians are long gone while our current technology is not doing everything which we believed it would. There are still many physicians who were
taught "the old ways" and many students who will resist, but sometimes we need to go back in time to move forward.
The diagnosis was in the history and initial vital signs.
Thomas Perry, MD,CM | University of British Columbia (Dept. of Medicine)
This is a classical presentation of life-threatening S. aureus infection that I have found underappreciated by many doctors and nurses. Vital signs should be interpreted in context. The temperature of a human taking naproxen around the clock (or other NSAIDs, acetaminophen, ASA, corticosteroids) is suppressed. To say it is "normal" or "low grade" misleads everyone involved. The heart rate was increased, and the story of severe back pain of relatively sudden onset weeks ago should be alarming.

I have seen too many people paralyzed or killed by S. aureus bacteremia and metastatic spread after an
identical story. The pain can arise almost anywhere (e.g. neck, shoulder, knee, pubis, muscle, as well as back). This man had sudden unexplained pain, or pain out of keeping with "injury". The temperature was very close to normal. In our societies, people experiencing sudden pain usually take acetaminophen or NSAIDs.

We (wrongly) teach our housestaff to prescribe "acetaminophen for fever", deliberately suppressing a crucial vital sign. One generation passes this practice on to the next. We fail to teach that beta blockers and some other drugs suppress tachycardia. Be grateful that we don't teach people to suppress tachypnea with opioids.

S. aureus loves to seed almost any tissue: joints, kidneys/urine, bone, epidural space, meninges, brain, lungs and pleura, even muscles and subcutaneous tissues. It does so easily during intermittent or continuous bacteremia, even without endocarditis. In this setting, look for other metastatic foci, even if it doesn't change treatment. One may at least wish to consider draining them where feasible.

Listen: the patient is telling you the diagnosis. (Osler)