July 2014 Critical Care Case of the Month: There Is Still a Role for Physical Examination

Robert A. Raschke, MD 

Banner Good Samaritan Medical Center

Phoenix, AZ

History of Present Illness

A 90-year-old woman was the seatbelt-restrained driver in a low speed frontal motor vehicle collision with airbag deployment, after she accidentally hit the gas instead of the brake. In the emergency room, the patient’s main complaint was right shoulder pain. On ER physical exam, she had sternal ecchymosis consistent with “seatbelt sign”. Her right shoulder was said to be tender, but the mechanism of injury to the right shoulder was unclear since her drivers-side seatbelt would been in contact with her left rather than right shoulder. Her right upper extremity was said to be “weak secondary to pain”. Further neurological examination was noted to be difficult due to “patient crying out in pain and anxiety”, but it was noted that she could lift both legs off the bed. Her left knee was echymotic. Cardiac auscultation revealed irregularly irregular rhythm.

PMH

• Chronic atrial fibrillation
• Coronary artery disease
• Hypertension

Medications

• Warfarin
• Aspirin
• Clonidine
• Metoprolol

Labs performed in the emergency room showed an INR 1.9. Radiographs demonstrated a normal right shoulder and a left patellar fracture. CT scans of the cervical spine and chest showed no bony abnormalities. An incidental 4 cm thoracic aortic aneurysm was noted. CT of the brain showed periventricular white matter hyperlucencies consistent with small vessel disease. The patient became a bit drowsy after receiving narcotic analgesia in the emergency room and was transferred to the medical ICU for management of pain and delirium.

ICU Physical Examination

In the medical ICU the patient was alert, and seemed much younger than 90 years of age, with a sharp wit. She complained of 10/10 shoulder pain at rest which occasionally made her wince, cry out in pain and move her shoulder – however, she said there was no position in which her shoulder did not hurt. There were no ecchymosis of the shoulder, and it could be passively abducted and rotated without worsening the pain. The initial neurological examination was cursory and unrevealing because the patient was distracted by pain, and her left leg was immobilized.  A short time later the nurse reported that she felt the patient’s right leg was weak and the neurological exam was repeated. Strength in the patient’s right leg was 1/5, her left leg was immobilized, but ankle extension was 5/5. She could not cooperate well with strength testing of her painful right arm, but her right grip was 2/5 with a normal strength in her left arm and hand. Toes were down-going and reflexes were generally hypoactive. She was not aphasic. Neurology was consulted.

Which of the following is true in regards to this patient’s neurological findings? (Click on the correct answer to proceed to the next panel)

1. A cervical spinal cord injury could explain these findings
2. A seat belt injury of the left carotid artery could have resulted in traumatic dissection and subsequent stroke
3. Right hemiparesis without aphasia could represent a lacunar stroke
4. They might represent a cardio-embolic stroke related to her history of atrial fibrillation
5. All of the above

Reference as: Raschke RA. July 2014 critical care case of the month: there is still a role for physicial examination. Southwest J Pulm Crit Care. 2014;9(1):8-14. doi: http://dx.doi.org/10.13175/swjpcc086-14 PDF