Case 14: Physical Exam

Case 14 Index

Vital Signs: Temperature 98°F, Blood Pressure 115/62 mmHg, Heart Rate 75 beats/min, Respiratory Rate 16 breaths/min
General Appearance: Chronically ill-appearing, cachectic man
HEENT: Normal conjunctiva, no scleral icterus, clear oropharynx
Lymph: No lymphadenopathy
Cardiovascular: No JVD, regular rhythm, no pericardial rubstethoscope
Pulmonary: Breath sounds normal bilaterally, no rales/rhonchi/wheezes
Abdominal: soft, non-tender, non-distended
Extremities: warm and well perfused, 1+ peripheral edema of lower extremities
Neurologic: Sleepy but arousable, answers very few questions with one word answers, no focal deficits, asterixis
Skin: Warm, dry, no rash

The patient’s daughter looks concerned and tells you, “The doctor in the hospital told me he may need to start dialysis. Is that true?”

How do you respond?
Well, it definitely seems as though his kidneys are failing and dialysis may be clinically indicated in another patient with the same signs and symptoms, but your father is quite frail. Are you sure this is what he wants?
While your clinical assessment of this patient may be correct and it will be essential to discuss the patient’s goals, this would not be the best way to approach this question. Try again, and let’s see if we can’t find a better way to get the discussion started!
I want to make sure I address all of your questions. Let’s take a step back for a moment. Would you mind sharing with me a bit more of what the doctors have told you in the past?
Nice work! It is crucial to let patients and their families know their concerns will be addressed. The question about starting dialysis is a very important one, but it is best to assess their understanding of the situation to find a good starting point.
Based on his symptoms and recent laboratory studies, it does seem like it is time to start dialysis. Can I tell you a bit more about how we’ll get started?
While your clinical assessment might be correct, take a step back and figure out where your patient and their family are at in this process. It is certainly a good strategy to ask permission to give more information about dialysis, but let’s try to assess their understanding first. Try again!
I appreciate your concern, but we really shouldn’t worry about dialysis until I’ve checked labs here and done a full assessment.
While you are right to put off any decision about dialysis until you get to know this patient more, this might not be the best approach. Telling someone not to worry may provide false reassurance or invalidate their concerns. Give it another try!

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