Physical examination in the care of medical inpatients: an

Transcription

ARTICLES
Physical examination in the care of medical inpatients: an
observational study
Brendan M Reilly
Summary
Background Little is known about the clinical importance of
skilled physical examination in the care of patients in
hospital.
Methods Hospital records of a systematic consecutive
sample of patients admitted to a general medical inpatient
service were reviewed retrospectively to determine whether
physical findings by the attending physician led to important
changes in clinical management. Patients with pivotal
physical findings were defined by an outcomes adjudication
panel as those whose diagnosis and treatment in hospital
changed substantially as a result of the attending physician’s
physical examination. Pivotal findings were classed as
validated if the resulting treatment change involved the active
collaboration of a consulting specialist. Findings were
classed as discoverable if subsequent diagnostic testing
(other than physical examination) would probably have led to
the correct diagnosis. Class 1 findings were those deemed
validated but not discoverable.
Findings Among 100 patients, 26 had pivotal physical
findings (26%; 95% CI 18–36). 15 of these (58%;
95% CI 37–77) were validated (13 with urgent surgical or
other invasive procedures) and 14 were discoverable (54%;
95% CI 33–73). Seven patients had class 1 findings (7%;
95% CI 3–14).
Interpretation Physical examination can have a substantial
effect on the care of medical inpatients. If replicated in other
settings, these findings might have important implications for
medical educators and quality improvement initiatives.
Introduction
Concerns about physicians’ declining bedside skills have
prompted the US National Board of Medical Examiners
to propose that, beginning in 2004, physicians-in-training
must demonstrate competence in physical examination
before they can receive a medical licence. Currently, only
about a quarter of US medical schools require their
students to pass such tests as a condition of graduation.
However, even if all physicians acquire basic skills in
physical examination, will they maintain and improve those
skills throughout their professional careers? Very few
residency programmes include physical diagnosis in their
curricula.1,2 Specialty board-certification examinations no
longer require an oral component with demonstration of
bedside skills. Continuing medical education conferences
rarely offer opportunities to update skills in hands-on
examination. Indeed, the time pressures of modern
practice, combined with advances in diagnostic technology,
seem to undermine the value of these skills. Is expertise in
physical examination still important in clinical medicine?
This question is reminiscent of scepticism in the 1980s
about the importance of the autopsy. At that time,
declining hospital autopsy rates prompted Goldman and
colleagues3,4 to compare the value of autopsies in periods
before and after the availability of new diagnostic imaging
technologies. These investigators found that the autopsy’s
yield remained substantial (major diagnoses unsuspected
pre-mortem in 22–25% of patients), undiminished from
1959 through 1985. Their findings energised efforts to
revive the autopsy as an essential quality improvement
process in hospitals.
Thus, it seems noteworthy that no previously published
studies have addressed the clinical importance of physical
examination in the care of patients in hospital.
Lancet 2003; 362: 1100–05
Methods
Background
In the week after completing a rotation as an attending
physician in a hospital, this author began teaching an
introductory physical diagnosis course to second-year
medical students. In response to students’ questions
about the importance of physical examination in the care
of inpatients, I searched PubMed for English-language
medical published work from 1966 through 2001.
Finding no data directly relevant to this question, I
reviewed the medical charts of all patients who had been
admitted to my own inpatient service during my justcompleted hospital rotation.
Department of Medicine, Cook County Hospital and Rush Medical
College, Chicago, Illinois, USA (B M Reilly MD)
Correspondence to: Dr Brendan M Reilly, Cook County Hospital,
Room 2129, 1901 West Harrison Street, A-1502, Chicago,
IL 60612, USA
(e-mail: [email protected])
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Outcome measures
The primary study outcome was the proportion of patients
in whom physical examination by the attending physician
detected so-called pivotal findings. A pivotal finding,
defined before any charts were reviewed, was an
observation by the attending physician that: (1) was determined by inspection, percussion, palpation, auscultation, or
other bedside physical assessments; and (2) prompted
THE LANCET • Vol 362 • October 4, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet publishing Group.
ARTICLES
revision of the patient’s initial diagnosis formulated by
medical house staff and emergency physicians; and (3) led
to a major change in the patient’s clinical management in
hospital. It was assumed that this outcome measure would
underestimate the overall effect of physical examination on
patients’ care but it would also increase the reliability and
clinical importance of the study’s findings.
Thus, not all patients in whom the attending physician
disagreed with previous examiners’ physical examination
(or their diagnosis or treatment) qualified as having pivotal
findings. For example, patients not designated as having
pivotal findings included: (1) a patient admitted with
n
Cardiovascular
Acute ischaemic disease
Congestive heart failure*
Syncope or arrhythmia
Valvular disease
26
12
7
5
2
Pulmonary
Asthma
COPD
Sleep apnoea syndromes
Empyema
Infected bulla
14
6
4
2
1
1
Infectious disease
Sepsis/bacteraemia
Bacterial pneumonia
Pneumocystis pneumonia*
Endocarditis
Disseminated strongyloidiasis*
Lung abscess
Perinephric abscess
Mononucleosis
Erysipelas
13
3
3
1
1
1
1
1
1
1
Gastrointestinal/hepatic
Acute pancreatitis
Gastrointestinal bleeding
Advanced liver disease*
Crohn’s disease
Acute cholecystitis
Infected pancreatic pseudocyst
Chronic diarrhoea
Abdominal pain, unknown cause
13
3
3
2
1
1
1
1
1
Total
Type of pivotal finding
New
17
Rejected
5
Confirmed
4
but conflicted
Total*
Validated Discoverable Class 1 Class 2
11
2
2
26 (100%) 15 (58%)
7
4
3
14 (54%)
6
1
0
11
4
4
7 (27%) 19 (73%)
*Numbers in parentheses are row percentages (denominator, n=26).
Table 2: Classification of pivotal findings of physical
examination
syncope who was found by the attending physician to have
intermittent third-degree heart block (a change in
diagnosis) that required a pacemaker (a change in clinical
management) but was not discovered by the physical
examination per se; (2) a patient admitted for gastrointestinal bleeding found to have hepatomegaly and
cutaneous spider angiomata whose initial diagnosis
(bleeding duodenal ulcer) and treatment did not change as
a result of these findings; and (3) a patient admitted for
treatment of lung abscess whose pleural friction rub
prompted a change in diagnosis (complicated parapneumonic effusion without lung abscess) but not a major
change in clinical management (antibiotic therapy without
surgery).
Table 1: Primary clinical problems necessitating hospital
admission in 100 patients
Patients and setting
Study participants included all patients admitted to one
general medical service team at Cook County Hospital, a
700-bed urban public teaching hospital, during a
consecutive 28-day period in January and February, 2002.
The hospital’s general medical service is staffed by
12 admitting teams, each comprising one attending
physician, two senior residents, two interns, and two
medical students. General medical service admissions
include all medical admissions to the hospital except
patients admitted directly to the coronary care unit, the
medical intensive care unit, or the subspecialty HIV service
(some patients with HIV disease are admitted to the general
medical service). Each of the general medical teams admits
about ten to 14 patients every fourth day during 24
consecutive hours. There is no float system during nights,
weekends, or otherwise; one senior resident supervises up
to ten daytime team admissions (0700 h–2200 h) and the
other senior resident supervises four to six night-team
admissions (2200 h–0700 h). All admissions are distributed
sequentially among three on-call teams, in order of patients’
presentation for admission (about 90% originate in the
emergency department). Thus, patients admitted to each
attending physician’s team represent a systematic, but not
random, sample of all patients admitted to the hospital’s
general medical service.
The hospital’s institutional review board gave ethics
approval for the study. Patients’ informed consent was not
required.
I examined all patients alone, no more than 7 h after
their admission to the inpatient ward, according to my
usual practice—ie, to examine all patients admitted during
daytime on the call day, and to assess all those admitted at
night early the following morning, before post-call rounds
at 0700 h. The physical findings, were not, in any case,
discussed with house staff or written in the patient’s chart
until after the house staff had recorded their own physical
findings in the charts. Most patients had also been
examined in the emergency department by both an
emergency medicine resident and an emergency medicine
attending physician. Because of required days off for house
staff and students, I was the only physician who examined
all study patients on every day of their hospital stay.
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Neurological/psychiatric
Status epilepticus*
Neurosyphilis
Pseudotumour cerebri
Pick’s disease
Stroke
Major depression
Paraplegia, decubitus
Vertigo
9
2
1
1
1
1
1
1
1
Oncology/haematology
Acute leukaemia*
Lung cancer
Lymphoma
Myelodysplasia
Medulloblastoma
Head and neck cancer
8
2
2
1
1
1
1
Renal
Acute renal failure
Nephrotic syndrome
Haematuria
7
4
2
1
Miscellaneous
Diabetic syndromes
Polyarthritis
Cervical disc herniation
Delirium tremens
Hypoglycaemia
Hypocalcaemic tetany
10
4
2
1
1
1
1
COPD=chronic obstructive pulmonary disease. *One patient with each of these
diagnoses died in hospital.
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Physicians
This author is a board-certified internist and geriatrician
who completed postgraduate training 25 years ago and
has been an active clinician-educator in teaching hospitals
ever since. For the past 7 years, my primary clinical
responsibilities have been those of a hospitalist
(3–4 months every year). All the emergency medicine
attending physicians are board-certified in emergency
medicine. More than 95% of the hospital’s internal
medicine and emergency medicine residents pass their
Initial diagnosis
Initial management
Chart review
I reviewed and abstracted all patients’ charts. The chart
review process was standardised by use of the stereotypical
format of the author’s chart notes: in keeping with my
Physical finding
Final diagnosis
Final management
Knee and ankle effusions
Polyarticular gout
Corticosteroids
IV antibiotics
Tender antecubital cord†
Suppurative thrombophlebitis Surgical thrombovenectomy (V)
New physical findings detected
Fever, suspected nosocomial
IV antibiotics
bacteraemia
Staphylococcal bacteraemia
from arm cellulitis
respective specialty board-certification examinations on
their first attempt. As a group, the hospital’s medical
residents score well above the national average on
American Board of Internal Medicine certification
examinations.
Fever, suspected UTI
IV antibiotics
Dusky big toe*†
Toe gangrene
Toe amputation (V)
FUO, suspected TB
Four TB drugs
Hepatomegaly*
Large-cell lymphoma (D)
Liver biopsy, chemotherapy (V)
Dialysis-catheter-related sepsis
IV antibiotics
AI murmur, wide pulse
pressure*
Bacterial endocarditis (D)
Aortic valve replacement (V)
Recurrent pyelonephritis
IV antibiotics
Peritoneal signs*
Ruptured perinephric
abscess (D)
Nephrectomy (V)
SLE with arthritis, pleuritis,
and fever
Corticosteroids
Synovitis and deformity of
MCP and PIP joints*
Pneumonia and rheumatoid
arthritis (D)
Antibiotics and methotrexate (V)
Sepsis, renal failure
IV antibiotics
Erythema and induration at
dialysis catheter site*†
Dialysis catheter tunnel
infection
Replace dialysis catheter (V)
Symptomatic SIADH
Fluid restriction
Orthostatic hypotension*
Volume depletion
IV saline
Delirium
Haloperidol, CNS imaging Psychomotor retardation,
normal attention span*†
Major depression
Antidepressants and intensive
psychiatric care (V)
Cerebellar infarction
Acute cholecystitis
CNS imaging
IV antibiotics, imaging
studies
Nylen-Bárány manoeuvre*
Absent liver dullness
Benign positional vertigo (D) Epley exercises
Pneumoperitoneum from
PEG tube replacement (V)
leaking PEG tube (D)
CHF from ischaemic
cardiomyopathy
CHF drug therapy
Right ventricular heave*
Cor pulmonale (D)
Home oxygen
Unstable angina
Heparin, aspirin
C8 radiculopathy with
weakness*†
Cervical disc herniation
Laminectomy (V)
AML, anasarca due to
hypoalbuminaemia
Socium restriction,
nutrition
Elevated jugular venous
pressure
Cardiomyopathy
CHF drug therapy
NSAID-induced acute renal
failure
Dialysis
Wrist drop*†
Wegener’s granulomatosis
Renal biopsy (V), cytotoxic
therapy, stop dialysis
Renal failure from HIV
nephropathy
Fluid restriction
Orthostatic hypotension*
Prerenal azotaemia from
acute pancreatitis
IV saline
Previous examiners’ physical
finding rejected
Surgical abdomen, cholangitis
Probably laparotomy
No peritoneal signs†
Disseminated strongyloidiasis Ivermectin, no laparotomy (V)
Thyroid storm from acute
thyroiditis
Methimazole, iodine,
and atenolol
No thyroid enlargement or
tenderness*
Mononucleosis (D)
Expectant
Myxoedema and tetany from
neoplasm
Neck imaging, surgical
consultation
No neck mass*
Hypothyroidism and
hypoparathyroidism (D)
Thyroxine, calcium, no neck
imaging
Bacterial pneumonia
IV antibiotics
No focal crackles or dullness
on lung examination*
Influenza (D)
Stop antibiotics
CHF
CHF drug therapy
Visualised venous pressure
normal*
Nephrotic syndrome (D)
Renal biopsy (V), stop CHF
therapy
Lymphangitic streaking and
tender adenopathy*
Recurrent erysipelas
(streptococcal)
IV penicillin, monthly penicillin
prophylaxis
4/6 systolic murmur at
pulmonic area*
Pulmonic stenosis with
post-stenotic pulmonary
artery dilation (D)
No mediastinal biopsy (V)
Physical findings confirmed but
attending physician disagreed
about implications
Recurrent staphylococcal
IV vancomycin
cellulitis
Mediastinal tumour
Mediastinal biopsy
Prerenal azotaemia from
gastrointestinal bleeding
IV fluid, blood transfusion, No orthostatic changes in
endoscopy
blood pressure or pulse
Hepatorenal syndrome (D)
Band oesophageal varices,
assess for liver transplant (V)
Non-dominant hemispheric
stroke
Add clopidogrel to
aspirin, CNS imaging
Pontine lacunar infarct (D)
Treat hypertension and diabetes,
no clopidogrel
Pure motor deficit*
D=discoverable. V=validated. IV=intravenous. UTI=urinary tract infection. FUO=fever of unknown origin. TB=tuberculosis. AI=aortic insufficiency. SLE=systemic lupus
erythematosus. MCP=metacarpophalangeal. PIP=proximal interphalangeal. SIADH=syndrome of inappropriate antidiuretic hormone secretion. CHF=congestive heart
failure. AML=acute myelogenous leukaemia. NSAID=nonsteroidal anti-inflammatory drug. PEG=percutaneous endoscopic gastrostomy. *Physical finding on first
hospital day. †Class 1 findings.
Table 3: Patients with pivotal physical findings (n=26)
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usual practice, chart notes in all cases briefly summarised
the patient’s presenting problems and then specified
agreement with previous examiners’ written findings
except for (“agree with above except”) specific aspects of
the history, physical examination, or test interpretation
with which I disagreed. Disagreements noted about
physical findings were categorised as one of three types: (1)
new (findings noted by the attending physician but not
noted by previous examiners); (2) rejected (findings noted
as present by previous examiners but deemed absent by the
attending physician); or (3) confirmed but conflicted
(previous examiners’ findings confirmed by my
examination, but I disagreed about the implications of
those findings for a patient’s diagnosis and treatment).
Adjudication and classification of outcomes
Based on initial chart reviews, details of patients judged to
have had possible pivotal findings were presented to an
adjudication panel of three senior attending physicians
(not including myself), who then decided which findings
met the study outcome definition of pivotal. Physical
findings were deemed pivotal if there was unanimous
agreement by the panel.
To further classify the relative clinical importance of
pivotal findings, the adjudication panel also decided by
consensus whether the patient’s change in diagnosis was
discoverable and whether the resulting change in
treatment was validated. A pivotal finding was deemed
discoverable (and, thus, less consequential) if, in the
opinion of the adjudication panel, the correct final
diagnosis would probably have been discovered in
hospital by subsequent technological testing (indicated for
the initial diagnosis), even if the pivotal physical finding
had not been found. For example, the finding of massive
hepatomegaly extending below the iliac crest in a patient
admitted from central America with fever of unknown
origin (initial diagnosis: disseminated tuberculosis) was
judged to have been discoverable, because abdominal
imaging (indicated for the assessment of fever) would
probably have led to the final diagnosis (primary diffuse
large B-cell hepatic lymphoma without tuberculosis). A
pivotal finding was deemed validated (and, thus, less
subjective) if the resulting change in treatment required
the intervention of a consulting specialist (for example,
lymphoma chemotherapy by an oncologist). Thus
defined, validation meant that an independent consultant
actively corroborated the change in diagnosis and
treatment prompted by the attending physician’s pivotal
physical findings.
Pivotal findings that the adjudication panel considered
validated but not discoverable were designated class 1
because
such
findings
seemed
unambiguously
consequential. All other pivotal findings (validated but
discoverable, not validated and not discoverable, not
validated and discoverable) were designated class 2.
Data analysis
Fisher’s exact test and exact (Clopper-Pearson) 95% CIs
were used to compare proportions.
Role of the funding source
The sponsors of the study had no role in study design,
data collection, data analysis, data interpretation, or
writing of the report.
Results
100 patients were admitted to my service during the
28-day period. Patients’ mean age was 55 years; their
median hospital length of stay was 3 days. Patients’
principal final diagnoses are listed in table 1. Six patients
died in hospital. For 28 patients, various language barriers
affected my initial clinical assessment.
Chart review identified 37 patients with possible pivotal
findings. The adjudication panel rejected 11 of these
because they did not meet all the criteria; the remaining
26 (26%; 95% CI 18–36) met the study definition of
pivotal findings (table 2). These findings were categorised
as new in 17 patients, rejected in five patients, and
confirmed but conflicted in four patients. Pivotal findings
were judged to be validated in 15 patients and
discoverable in 14. Frequency of pivotal findings was
similar in patients with or without language barriers and
in patients who died in hospital or survived to discharge.
In 20 patients, pivotal findings were recorded on the first
hospital day, and in the remaining six the findings were
noted later in the hospital course.
In seven patients (7%; 95% CI 3–14), pivotal findings
met the definition of class 1 findings (validated but not
discoverable). Among the remaining 19 (class 2) pivotal
findings, eight were validated but discoverable, five were
neither validated nor discoverable, and six were
discoverable and not validated (table 3). Consultants’
validation of pivotal findings involved emergency surgical
procedures in seven patients (six done, one cancelled);
cytotoxic chemotherapy in three (two preceded by invasive
diagnostic
procedures);
interventional
radiological
procedures in two (one done, one cancelled); invasive
diagnostic procedures not followed by cytotoxic
chemotherapy in two; intensive psychiatric care in one;
and assessment for emergency liver transplantation in one.
Discussion
These results show that physical examination can have a
substantial effect on the care of medical inpatients. About
one in every four (26%) patients in the present
investigation had pivotal physical findings. In many
patients, these findings prompted active collaboration by
specialist consultants to perform urgent surgical (or other
invasive) procedures. The seven patients with class 1
findings were especially important because diagnostic
testing other than physical examination would probably
not have led to the necessary change in treatment. By
contrast, most of the class 2 findings were discoverable;
identification of the findings during the physical
examination might have improved the timeliness (and
hence quality) of care, but might not have affected final
treatment decisions.
These results approximate analogous findings in studies
of the autopsy, in which 21–25% of patients had class 1
(8–12%) or class 2 postmortem findings.3,4 This parallel
will not surprise experienced clinicians who believe that
skilled physical examination, like the autopsy, helps them
as much today as it did in the past.5 But the findings of the
present study suggest that physical examination, unlike
the autopsy, can help patients too.
Previous studies about physical examination have
focused largely on assessment of trainees’ skills and
interventions to improve them.6-13 Laudable efforts have
also been made to critically appraise the accuracy and
reliability of particular physical findings in specified
clinical contexts.14,15 But the clinical importance of these
efforts is unknown. A few investigators have compared the
relative value of history and physical examination in the
diagnosis of outpatients.16-18 However, no such studies
have addressed the treatment of inpatients.
The present study was not designed to compare the
accuracy of physical examination by more and less
experienced physicians—such a study would, additionally,
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require independent gold standard assessment of the
attending physician’s physical findings. Nor do these
findings prove that skilled physical examination improved
patients’ outcomes—it may have done so, but this
conclusion would require a control group in whom
physical examination was not done, which would be an
unethical study design. Instead, I have estimated the
frequency with which physical examination can contribute
to the process—and, arguably, the quality—of inpatient
care. The results lend strong support to a venerable, if
unverifiable, axiom of clinical medicine: sick patients need
careful physical examination, the more skilled the better.
The mundane nature of our pivotal physical findings
(table 3)—none of them rare or esoteric—may cause some
to question the external validity of our results. Do they
simply show the inadequacies of one institution or group
of physicians? Probably not, because it is precisely these
types of common physical findings that elude physicians
elsewhere.6,9,11
Nevertheless, the generalisability of these findings is
uncertain. Our results involved only one institution, a
28-day period (perhaps atypical), one attending physician,
and a fairly small (consecutive but not random) sample of
patients. It is possible that the frequency and effect of
pivotal physical findings vary with differences in variety of
cases, patients’ acuity of illness, and physicians’ skill,
motivation, and time. Investigations in other settings are
needed.
However, this does not mean that large multicentre
studies should be undertaken to investigate the usefulness
of inpatient physical examination. Clearly, as shown in the
present study, skilled physical examination facilitates high
quality care in some cases. The relevant question for
further research is: which cases? This question will be a
moving target as diagnostic technologies evolve, potentially
replacing aspects of physical diagnosis as the standard of
care. But, like the autopsy, physical examination should
remain the standard of care until proven superfluous or
cost-ineffective; hence the importance of documenting its
effectiveness and promoting its accomplishment.
Otherwise, future studies comparing technological and
physical diagnosis may have spurious results with
untoward consequences: increasing dependence on costly
diagnostic technology, and decreasing confidence in
physicians’ clinical skills.
Pending further research, then, the present investigation
warrants attention for three reasons. First, the intervention
proposed by the US National Board of Medical Examiners
to test students’ bedside skills will use outpatients. This
process may not adequately measure the skills needed to
care for sick inpatients. One way to find out would be to
monitor the success of these efforts by use of methods from
the present study. To do so, attending physicians in
teaching hospitals must undertake their own independent
physical examination of all inpatients for whom they are
responsible (although such practice is expected, it is not
always the reality in US teaching hospitals today). If
substantial shortcomings remain, major curricular reform
will be needed in medical schools and postgraduate
training programmes.7-10,12,13 Such change is easier said than
done,19,20 in view of the many competing demands for
curricular time at all levels of medical education.
Second, highly publicised efforts to improve the quality
of hospital care largely ignore this issue. Calls to reduce
preventable errors in hospitals have focused more on
treatment errors than on diagnostic errors, and they have
emphasised the need for improvement in systems rather
than in clinicians.21,22 But surely many treatment errors
result from diagnostic errors, and, as the findings of the
1104
present study imply, some of these might be preventable
by improvement in clinicians’ skills. This fact does not
obviate the need for computerised order entry, analyses of
root causes, constraints models, or other promising
systems approaches to quality improvement.23,24 It simply
makes the obvious point that better systems will improve
care more if better clinicians use them.
Finally, evidence-based medicine has been redefined
recently to pay greater homage to clinical expertise, the
essential skill needed to integrate best current evidence
with the patient’s clinical condition and preferences when
making decisions.25 This change sounds correct, and it is
an improvement on earlier definitions that seemed to pit
researchers against clinicians; but it is only a beginning. In
fact, enthusiasts of evidence-based medicine devote most
of their attention not to clinical expertise but to other
priorities: medical informatics, critical appraisal of the
literature, and health services research skills.26,27 No doubt
these powerful instruments will be important, in view of
the complex challenges of evidence-based quality
improvement. But the practice of evidence-based
medicine is the practice of medicine, not the practice of
evidence. The findings of the present study suggest that
more attention should also be paid to understanding and
implementing the power of physicians’ traditional clinical
skills.16,28-32
Conflict of interest statement
None declared.
Acknowledgments
I thank Arthur Evans, Christopher Smith, and Brian Lucas for serving as
the outcomes adjudication panel for the present study, and Dr Evans for
his insightful review of the manuscript. The invaluable help of the Cook
County Hospital emergency physicians and medical house staff who cared
for the study patients is also gratefully acknowledged. Funding for this
investigation was provided by the Department of Medicine, Cook County
Hospital.
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Clinical picture
Gallstone ileus
Jayant S Vaidya, Olutunde Lalude, David Grant, Hasan Mukhtar
A 73-year-old woman presented with 5-day history of
colicky abdominal pain, distension, vomiting, and signs of
peritonism in the lower abdomen. She had no history of
biliary pain. An abdominal radiograph showed dilated
loops of small bowel, air in the biliary tree and gall
bladder (figure, thick arrows), and a peripherally radioopaque stone in the bowel (figure, thin arrow). We agreed
on a preoperative diagnosis of gallstone ileus. At surgery
the 3·5 cm solitaire gallstone was found in the distal
jejunum with two 5 mm perforations close to the site of
impaction. These perforations were probably at the sites
of two previous impactions. The closest perforation was at
the mesenteric border and required resection of a small
segment of jejunum. There were dense adhesions around
the gall bladder, but these were left alone. Apart from a
slight wound infection, the patient made an uneventful
postoperative recovery.
Department of Surgery (J S Vaidya FRCS, O Lalude FRCS, H Mukhtar
University College Medical School, London N19 5NF, UK
FRCS)
and Radiology (D Grant FRCR), Whittington Hospital, Royal Free and
1105

Physical examination in the care of medical inpatients: an

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