Physical Exam: Call to arms/legs

To those of you who were hoping my most recent post in the physical exam series was the end of the series, sorry, there\’s plenty more ground to cover.
To those who were looking forward to my posts on the uh…naughty bits (I know Frank is among them), I must also disappoint.  There was no way I could write on those subjects without making it NSFW.  I also suspect that my Google hits would skyrocket, but not with the kind you\’d want your mom to meet.

So, to save my mom, I will shift the focus on the exam of the extremities.

Physicians have many ways of writing out the exam of the extremities, depending on their specialty.  As a PCP, I have seen the extremity exam written in several ways:

• Ext – MAEW – translation: Extremity exam: Moves all Extremities Well
• Ext – No edema – translation: No swelling in the legs
• Ext – No c/c/e – translation: Extremity exam: No clubbing, Cyanosis, or Edema.

Others, depending on the moon-phase, emotional state, and time-schedule of the examining physician.

The first was the exam as written by pediatricians where I trained.  It mainly was used for newborns, indicating that nothing got messed up in the process of being born.  This is an important thing to note.

The second is the more common way I\’ve seen (and written) the exam of the extremities.  It is short, to the point, and uses slashes (which doctors seem to like writing).  Of course, this begs the question, \”what the heck is clubbing, cyanosis, and edema?\”

Thanks for asking, although you didn\’t need to beg.

Clubbing – What it\’s not

Greenpeace activists can relax, as this has nothing to do with baby seals.  We don\’t examine baby seals very often, and I doubt their extremities get clubbed.  At least I hope they don\’t.

Clubbing also doesn\’t refer to something one might find on an episode of the Flintstones.  The animators for that show had trouble with the torso, much less the hands and feet.  The clubs you did see on that show are not the kind we see our patients carry.  If they did carry that kind of club, we wouldn\’t simply notate it as \”clubbing present,\” but instead something like: \”Patient showed significant aggression towards the examiner, expressing his displeasure over the rectal exam.\”  This has never happend to me.

Clubbing does not refer to the practice of going out to several bars in an evening.  I am sure some of my patients do go clubbing in this way.  The only reason I would mention this kind of clubbing it would be if they were holding an alcoholic beverage in the exam room.  In this case, it probably wouldn\’t represent the carousing habits of the patient, it would more likely be a way to talk me out of doing a rectal exam.

Finally, clubbing doesn\’t refer to the style of golf I employ between shouts of frustration.

Clubbing – What it is

Credit

Clubbing has the following features:

1. Softening of the nail bed – The red part on the above picture is soft to touch
2. Loss of the normal <165° angle between the nailbed and the cuticle
3. Increased convexity of the nail fold – The nail bends downward at the tip
4. Thickening of the whole distal (end part of the) finger (resembling a drumstick)
5. Shiny aspect and striation (grooves/lines) of the nail and skin

Clubbing often happens for no known reason.  Perhaps the fingers didn\’t have anything better to do and thought clubbing could be fun, we just don\’t know.  I have repeatedly asked clubbed fingers for an explanation, but they have been anything but forthcoming.

The reason we look for clubbing is the association of this physical finding with certain diseases, including:

• Lung cancer
• Chronic lung disease
• Heart disease (especially congenital heart disease)
• Liver disease (including cirrhosis and hepatitis)

The thing about clubbing is that it really isn\’t that common.  Yes, some studies say that up to 1% of internal medicine patients can have clubbing, but my experience is that it is far less common than that.  I think the real reason doctors document this so often is more tradition than the importance of noting this on everyone who comes in with a runny nose.  It also gives an extra chance to use a slash.

Cyanosis – Feeling Blue

Cyanosis is a description of the phenomenon when a person\’s skin turns blue.  This can happen for several reasons:

• Saying something over and over (until they got blue in the face)
• A smurf ancestry is finally showing itself.
• Careless use of highlighter pens.
• The oxygen level in a person\’s blood is low.

The reason saying something repeatedly causes facial blueness is one of controversy.  Some have speculated that if the person did not take a breath between saying it, the oxygen level would drop and the percent of carboxyhemoglobin would rise.  Others have suggested shunting of blood away from the head (brain) would be the only good explanation of why someone would repeatedly say something.  Proponents of this theory point out that this would cause selective blueness in the head, while other causes blueness in the extremities as well, and nobody says \”blue in the hands and face\”.  Still others point point to the fact that saying something over and over is frequently associated with people attacking with highlighter pens.

The controversy rages.  We\’ll let the scientists fight this one out.

Since this is a post on the extremities, we don\’t really care about it.  What we care about is acrocyanosis. Acrocyanosis is when a person\’s hands and/or feet turn blue when the rest of the body do not.  When a person\’s blood oxygen level is low, the hands and feet are the first place to show it.  Acrocyanosis also happens when a person\’s core body temperature drops, causing their blood vessels to shunt blood away from their arms and legs.  As a kid I had a skinny friend who would always get acrocyanotic when he went swimming.  We didn\’t know what was the explanation, so we called him \”smurf boy.\”

Truthfully, acrocyanosis is uncommon enough that it probably doesn\’t merit inclusion in routine exams.  Doctors\’ love of slashes explains this again.  An exception of this is the newborn baby, where cyanotic heart disease is always a concern.  Certain congenital heart abnormalities result in the inability for the child to properly oxygenate their blood.  This may show up at birth, but can also be delayed in its presentation.  This is one of the main reasons pediatricians are reluctant to send babies home before 48 hours of age.

Medical professionals should be on the look-out for smurf heritage, as this can lead to misdiagnosis.  One of the major clues to this is the substitution of the word \”smurf\” for other words in common speech.  Wikipedia gives a cogent explanation of this:

A characteristic of the Smurf language is the frequent use of the word \”smurf\” and its derivatives in a variety of meanings. The Smurfs replace enough nouns and verbs in everyday speech with \”smurf\” as to make their conversations barely understandable: \”We\’re going smurfing on the River Smurf today.\”

When used as a verb, the word \”Smurf\” typically means \”to make\”, \”to be\”, \”to laugh\”, or \”to do\”. The word appears to serve the same function as the Spanish verb \”hacer\” or the French verb \”faire\”. It was implied a number of times that Smurfs still understand each other due to subtle variations in intonation.

Humans trying to communicate in Smurf language find that simply using the term \”smurf\” is not enough. In one adventure, Peewit explains to a group of bold fighters that the statement \”I\’m smurfing to the smurf\” means \”I\’m going to the wood\”, but a Smurf corrects him by saying that the proper statement would be \”I\’m smurfing to the smurf\”, whereas what Peewit said was \”I\’m warbling to the dawn\”. In other words, \”I\’m smurfing to the smurf\” and \”I\’m smurfing to the smurf\” are not the same.

He goes on to explain that: \”If you smurf: I\’m smurfing to the smurf then what you\’re smurfing is: I\’m smurfing to the smurf, and they\’ll smurf that you want to smurf to the smurf whereas you\’re smurfing to the smurf!\” The bold fighers hasten away in total confusion.^[7]

It\’s subtle, but nobody said medicine was easy.

Edema

Edema is another word for swelling.  Doctors say things like edema, acrocyanosis, and sphigmomanometer for several reasons:

• To impress potential mates
• To intimidate enemies
• To make their moms proud

There are problems with this, however, because the response of the recipients of these words can have unpredictable responses.  Enemies can become impressed and proud, and mates and moms can be intimidated.  The good news is that most people have none of these reactions, but instead simply say: \”huh?\”

The swelling to which the word edema is attached is usually in the legs.  This happens when fluid seeps from the blood vessels into the the tissue outside of them.  The exam is done by pushing a finger into the front of the lower leg and holding it for several seconds.  Edema is present when the pressure from the pressure leaves a dent.  This is called pitting.  The degree of pitting is equivalent to the severity of the edema.

• Trace pitting describes a small amount
• 1+ edema a little more
• 2+ more than that
• 3+ a whole lot less.  Just kidding.  It\’s a bunch.

This is a very subjective assessment, and the difference between 1+ and 3+  doesn\’t mean much – especially between different providers.

What edema means

Between c, c, and e, the e is the most common and hence the most clinically significant.  Really, docs should just write:

Ext – No e

or, for those who love slashes:

Ext – /////no/////////e///

Nobody does this, however.

Edema has a wide range of causes, from benign to life threatening.  The benign causes are the most common, and they include:

• Eating too much salt (also caled \”pringle\’s syndrome\”).
• Allergies – usually mild edema, and one of the few common causes of swelling in the hands.
• Hormones – female hormones are related to other hormones called mineralcorticoids which can cause fluid retention.
• Veins in the legs become less good at pumping blood back to the heart, causing what is known as dependent edema. This happens as people age, being worse in some people than others.  This can be severe enough to compromise blood flow to the soft tissue, resulting in a skin lesion called a stasis ulcer.

Edema can be a sign of more serious disease as well, including:

• Deep Venous Thrombosis (blood clot in the leg) – This generally presents with one leg swelling more than the other, although I have seen cases where it was in both legs at once.  A more abrupt onset or the onset after prolonged sitting (as in travel) are things that should raise suspicion of this.
• Heart failure – Blood is not able to be pumped back to the heart well because of a weakened heart.
• Lung disease – Any lung problem that causes the carbon dioxide level to stay up for longer periods of time can do this.  In my experience sleep apnea is a common cause of this and should be suspected as the cause if the patient has facial bruising (caused by being hit by a spouse).
• Kidney disease.
• Low protein levels in the blood due to liver disease, kidney problems, or malnutrition.  This causes swelling in the hands and even the face.

Treatment of edema depends on the cause.  In general, the best thing to do is to raise the legs and eat less salt.  Diuretics (water pills) are probably over-prescribed, as they can cause significant problems with a person\’s electolytes (sodium, chloride, potassium).  For those with dependent edema, wearing compression stockings may be the best (and most fashionable) option.