From head to toe

I am a creature of habit and tend to be little OCD at work, so there are lessons I have learned in medical school that I continue to utilize to this day as a hospitalist. One of those lessons that has served me well over the years is simply examining my patients from head to toe at every visit, regardless of their diagnosis. Specifically, examining a patient's legs has been instrumental for me in assessing and monitoring their overall volume status. When rounding with residents and medical students early on in my career, I tried to emphasize this component of the physical exam, as I would often see bedsheets untouched after an exam. When I see patients, I make it a point to routinely uncover and examine their legs to look for any acute changes. I'd like to share two examples from my practice when this simple habit came in handy.

In the hospital, I frequently manage patients with obesity who present with shortness of breath. Acute heart failure is typically in the differential. However, the classic exam findings, such as an elevated jugular venous distention (JVD), crackles on the lung exam, and third heart sounds on the cardiac exam, can sometimes be difficult to assess due to body habitus. Further, laboratory values like B-type natriuretic peptide (BNP) can be falsely low in patients with obesity. Chest X-ray can help if there is evidence of fluid overload such as edema and/or pleural effusions. Nurses do a great job of monitoring intake and output, but sometimes these measurements can be inaccurate due to incontinence, patient nonadherence, and just busyness on the floor. As such, I frequently depend on how the legs look over the course of the admission to monitor clinical progress.

Over the years of interactions with my patients, I frequently comment that I notice more wrinkles on their legs and let them know their volume status is improving. They often joke with me about the “wrinkle sign.” It's so heartening to see a patient who came in feeling so short of breath that they could not even hold a simple conversation start to smile and joke about how wrinkly their legs are.

Another example of the importance of a head-to-toe (leg) exam are cases when the patient already has an established diagnosis. The natural tendency is to focus on the one part of the body associated with the diagnosis. I once cared for a patient who was admitted for pneumonia. The signout from my colleague was to consider sending him home on oral antibiotics if he continued to progress well on the current antibiotic regimen. Given that it was the third day of antibiotics, I went into his room expecting him to be looking good and almost ready to go home. However, when I entered his room, he was sitting up, looking uncomfortable having difficulty finishing his sentences. This was not what I expected. He had obesity, so his physical exam was challenging as indicated previously. When I removed his covers and looked at his legs, I noted 3+ pitting edema bilaterally from his feet to his thighs. He reported no history of congestive heart failure. I recommended a cardiac evaluation and started him on IV furosemide for diuresis. The chest X-ray showed pulmonary edema, and the echocardiogram showed a low normal ejection fraction. The patient likely went into heart failure from receiving IV fluids as part of the sepsis protocol when he was admitted. After diuresis, he started to feel better and had less shortness of breath. There was also a notable decrease in the lower-extremity edema as his overall clinical status improved.

It is our duty as physicians to see our patients as a whole, from head to toe. From my experience, I have found the leg exam to be an invaluable component of my assessment. We manage complex patients and sometimes it's easy to overlook the simple things. But sometimes it's the simple things that can make all the difference.