Clinical Signs: Never Before Described Great Original Bedside Findings!

If your looking for a collection of excellent, original, never before described clinical findings at the bedside, you've come to the right place.  The Happy Hospitalist is proud to publish important clues every clinician should consider when formulating their medical plan.  Use them carefully and only in conjunction with common sense.  This collection may be updated at anytime.  Check back from time to time to get your CME!

THE TWENTY SIGN

Have you noticed, most ICU drugs are managed in a range of less than 20, whether it's units, mcg, mg, g. Everything is measured in small numbers. Get out side the ICU and you have to mulitply everything by 10.  Once you hit twenty of anything in the ICU, your Twenty Sign has arrived.

Happy's Twenty Sign has a very high positive predictive value (if your units are greater than 20, you have badness). For example, take a normal 45 year old male and give him acute medical illness, severe enough to land him in the ICU. Have him start the day without an inkling of a history of diabetes and with a normal HgbA1C of 5.5%.

And then get a call from the nurse saying he's up to 22 units per hour of intravenous regular insulin. That's the Twenty Sign at work. That's badness. When you are in the ICU and the nurse calls you to tell you your patient is on twenty of of anything, that's badness. Take notice of the Twenty Sign. Use it to your advantage. Don't let time slip away from you. When the Twenty Sign is invoked, you must act immediately to find that regulatory switch gone haywire.

The twenty rule also applies to alcoholics. I have cared for many a hardcore alcoholic in the depths of withdrawal. I once had a patient on 20 mg of ativan an hour. It was nuts. That's not normal. Let me put that in perspective. A non drinker would sleep for hours with just one mg.

In fact, I believe so strongly in the Twenty Sign, I believe it should rise to the same importance of the code blue.

Code Blue in room 763

Rapid Response Team to room 457

Team Twenty to room 342, STAT.

THE HONESTY SIGN:  HOW TO FIND A LOST CELL PHONE IN THE HOSPITAL

Ok, I'm sure most hospitalists and other doctors in the hospital have done this at one time or another in their career.  They've lost their cell phone while rounding and have to back track their steps to try and find it.   The good thing about the iPhone is that it has an app that can GPS track the cell phone should anyone ever decide to walk away with it.

But the app doesn't work well in big buildings like a hospital where the 'ping' area can only usually be pinged down to a city  block or so.   This is unlike at my home where I can follow the cell phone ping on another device and actually see the phone on an internet map moving from one room to another.

Fascinating stuff, but it doesn't help me if I've lost my cell phone in the hospital.  So, if you're wondering how to find it, just call the number.  That's what I did recently when I misplaced my cell phone during hospital rounds.  Who answered?  Why one of my patients, of course.  I recognized the voice, hung up and retrieved my phone in less than a minute.

In retrospect I think I've just created a new diagnostic test.  It's called Happy's honesty sign.   I believe it might come in handy when one is trying to determine if patients in pain are opiate seeking or if they are honestly having pain.  If you're honest about returning a brand spankin' new iPhone, you're more likely to be telling the truth about your need for pain medication.  So leave your phone in the room of a patient whom you question their motivation and you might find the answer you seek. I dare you.  If you're a student or a resident, it's time to tuck away Happy's Honesty Sign for future reference.

THE SQUARE ROOT SIGN

The brain is amazing. The more I do this hospitalist medicine gig, the more impressed I am with how complex upper motor neuron function can be.    I was taking care of an elderly 88 year old man who didn't know nothin'.  He didn't know what month it was.    He didn't know what year it was.  He didn't even know he was in the hospital.  The nurses were trying to get an IV in him.  Instead of doing my one question mini mental exam, I decided to kick it up a notch. 

Happy:  What's the square root of 16?

Old Man:  4?

Happy: What?

Old Man:  4.

Happy:  What's the square root of 25?

Old Man:  5.

Happy's shocked

Nurse:  He used to be an accountant.

Happy:  What's the square root of 144?

Old Man: 12
Happy: That's amazing.

The brain is amazing. And this guy is living proof.  Listen up doctors and nurses.  The next time you think your confused and demented old man doesn't have a clue, make sure you do Happy's square root sign before passing judgement as to their cognitive ability.  They might just surprise you.  

THE HANDSOME SIGN

So I'm rounding on a morbidly obese 84 year old admitted with acute delirium on advancing dementia. It's kind of sad. Here's a lady who's family hasn't made one appearance in the seven days she's been in the hospital. Not one. She's called a few of the nurses whores. She's even used the "N" word a few times. You'd think she was crazy and needed committed right?  You'd think she had a few harsh words for Happy, given his no nonsense approach to medical care, right?   Well, not exactly.

Mrs Smith: Who are you?
Happy: I'm your doctor. I've seen you everyday for the last week
Mrs Smith: You don't look familiar
Happy: I'll see you tomorrow Mrs Smith. I have to go now.
Happy walking away
Mrs Smith: Come back here son. I want to tell you something.
Happy walks back to listen closely.
Mrs Smith: You sure are a handsome young thing.

Something tells me she's not as confused as everyone thinks she is. In fact, given that she tests positive for Happy's Handsome sign, I think she's ready for discharge back to the community.  

STATUS ASTHMATICUS SIGN

Just when I thought I'd seen it all, along comes another hospitalist experience that gives me a double take. She was a 30 year old black female texting in the ER  right in the middle of her status asthmaticus attack.  Status asthmaticus is a severe form of asthma with findings that require continuous monitoring for progression to respiratory demise. This lady was on BiPAP, a form of external breathing support that helps people in respiratory distress to try and overcome their illness without ending up intubated.  She showed all the findings of impending respiratory failure from her status asthmaticus:

** Diffuse wheezing
** Poor expiratory air flow
** Accessory muscle usage
** Hypercapnea
** Tachypnea
** Tachycardia
** Prior history of being on a ventilator

She had all these poor prognostic signs.  All except one.  She couldn't get her eyes off her brand new iPhone 4 long enough to stop texting.  Maybe in her mind, this was her Last Supper.  Here's a lady who appeared to be  minutes away from ending up on a respiratory and she was too busy texing to take her eyes off her phone and answer some questions for me.  I call it the status textmaticus sign.  In retrospect, I think it may have been the smartest thing she did that night.   With all signs pointing to intubation, her texting rampage in the ER was a sign she just wasn't as sick as she objectively appeared.

ALLERGIES : OBSERVATION RATIO SIGN

After seven years as a hospitalist I have discovered another little known fact about hospitalist medicine.  When trying to decide whether or not a patient should be observation status or in-patient status, you need to look no further than the little known Allergies : Observation Ratio!  The more allergies the patient has, the more likely their admission will not meet insurance criteria for a full admission and the more likely they will have to be observation status.   If you have 57 allergies and one was to survey a random mixture of 100,000 MDs, RNs, PAs, NPs, LPNs, PharmDs and homeless people,  you would find 99,999 of them  would start thinking about their weekend plans  at the lake while the patient was describing their:

**  worst headache of their lives or
**  crushing chest pain that feels like an elephant sitting on their chest or
**  their abdomen that hurts all over when you push on it

Patients with 57 allergies should be prepared for health care professionals to not take them seriously,  most of the time, which is a shame when  you actually need someone to believe you that one time out of a 100,000.

DENTURE STAINS SIGN

So I'm taking care of an 84 year old demented old man who was admitted with severe  respiratory failure.  He's noted to be highly agitated, demented and has no idea of left from right.  After going into an inaudible tangent about nicotine patches, he tells me he quit smoking five years ago.  I'm not entirely sure why he wanted me to know that, except to say, he hadn't quit smoking and did in fact wreak of tobacco smell.  But, that wasn't going to stop my old guy from trying to convince me that he had quit smoking for good.  In fact what he told me next gets filed away with the rest of the funny things demented people say.

If you don't believe me you can take out my dentures and look for the denture stains.

That's actually a pretty intelligent thing to say for a man in the thralls of delirium.  I'd never thought of checking denture stains for smokers or tobacco abusers who have convinced themselves they have quit.  In addition to denture stains, other clues that folks are lying about their tobacco cessation efforts include 

• Nicotine and tobacco stains on the beard or mustache
• Yellow discolored fingers and nail beds on the smokers  fingers of choice
• Cigarette holes and stains in the clothing and the emanating stench of smoke
• Bad smokers breath
• The pocket sign.  A square imprint in the upper pocket or the round chew box sign in the jeans.

Oh, and for the other signs of tobacco abuse?  I forgot the obvious:  heart attacks, congestive heart failure, cancer, COPD, stroke, kidney failure, blindness, dementia, abdominal ischemia, peripheral vascular disease and leathery skin.  Those are some other tell tale signs that a smoker is in your presence.

THE BAND-AID SIGN

The Band-Aid sign:  One of my roles as a hospitalist is to assist other physicians in consultation for elevated blood sugars. Usually these straight forward consults are easy to address and quick to fix. Most of the time it's either a non compliant diabetic who either doesn't take their insulin or they had a run of poor food choices or they have uncontrolled diabetes due to acute illness. Every now and then something else is to blame.

Like the Band-Aid on their knee.

"Why Mrs Smith. What is that Band-Aid from?" I asked.

"I had a steroid injection in my knee yesterday", says Mrs Smith.

Another reason to lift up the covers on exam. It can make the diagnosis for you.

INTACT HUMOR REFLEX SIGN

Humor is often a good sign the patient can be discharged to home.   So I get asked to consult on a patient in the emergency room to admit for acute exacerbation of multiple chronic medical issues. Reading the nursing home transfer sheet clued me into exactly what the specifics were around the transfer.

92 year old female transferred for "confusion", "UTI", "3+leg swelling", "Neck and back pain" and "nausea and emesis".

That sounds like a sick lady. Especially at 92 years old. Something the American medicine can certainly provide for. Fortunately for me, hospitalist medicine is continuity of care for a very large sub population of the chronically ill who present with an acute exacerbation of multiplemedicalproblemitis

And this is a golden example of how hospitalist medicine brings value, not only to hospitals, but also to the Medicare National Bank. This sweet old lady just happened to be a bounce back of mine.  Perfect I thought, old lady, nursing home, multiple medical problems, sounds like the expected course of action. She'll need admitting for sure. Except she didn't. Because I knew her.

I knew

• The back pain was chronic
• The nausea and occasional emesis has been worked up since the Carter years, and has experienced the magic of American medicine first hand trying every test known to man.
  
• The edema was non existent. Fat legs do not equal edema. Especially when the rest of the body habitus confirms the diagnosis of adipose extremis.
• The UTI as well was a sham. I never believe urinalysis from anywhere, ever, unless it is collected by sterile cath technique. Urine from the ED? Crystal clear

Not to mention the chronic hypercapnic respiratory failure with a baseline CO2 of 70, a baseline creatitine of 1.8 and a pacemaker waiting to discharge its last electron from a sweetheart as big as gold.

The only thing left to address was her confusion.

Me: Why are you here in the ED today?
Her: I don't know, the nursing home sent me.
Me: I'm not sure I could do much for you in the hospital. Everything here in the ED appears to me like you have a 92 year old body.
Her: You're going to be 92 some day as well.

Final diagnosis: multiplemedicalproblemitis without exacerbation with intact humor reflex. ICD code 867.53.09. Disposition. Home. Intact humor reflex is always the best sign of intact cognition.

CALLING YOUR DOCTOR AN M'Fer SIGN

A few days ago I blogged about the sleeping husband sign and how it can be the cheapest yet most informative test available to ER docs everywhere. A reader responded with the MFer sign. In the interest of fostering a learning environment here in Happy's world, I thought this sign deserved front and center.

Don't forget the classic calling the doctor an MF'er sign. When done by a family member when you refuse to write their mother/brother/sister narcotics because they are malingering then you know that they are in on the game as well and need their drugs. Yes it happened to me. I did not write the narcotics and the patient's daughter got up to push me so I walked out of the exam room. The kicker is that the next day the patient called the office wanting a medical note to turn her power back on after she didn't pay the bill. If you or your family calls me an MF'er I don't turn on your power or write you narcotics.

Any others?

If you're a student or a resident,check out these other great clinical signs: