Case Presentation: A 68-year-old man presented with one week of weakness and fatigue. The patient had presented to the emergency department (ED) one week earlier with persistent bleeding from the left ear after a fall on a bus. At that visit, a recent history of easy bruising and persistent bleeding from minor injuries was noted. Physical examination showed left arm ecchymosis and left auricular hematoma with active oozing. Laboratory values showed an aPTT of 52.5 (reference range 25.4-34.9s), and hemoglobin of 12.3 (from the patient’s baseline of 14). The patient’s ear laceration was repaired, and he was discharged. The patient presented on current admission with progressive light-headedness, fatigue, and weakness. He was found to have a blood pressure of 65/49, heart rate of 120, hemoglobin of 8.7, and an aPTT of 84.3. He denied anticoagulant use. He reported an extensive surgical history without bleeding complications. Physical examination in the ED was significant for oozing of blood from the left helix, a large subungual hematoma, and significant swelling and ecchymosis of the left ankle. Guaiac-negative brown stool was noted by ED staff, but an examination of the back was not documented. More complete physical examination, including examination of the patient’s back and buttocks and rectal examination, was deferred due to difficulty of examining the patient in the busy ED. The next morning, laboratory data showed hemoglobin of 6.9 and aPTT of 80.4. The patient was thoroughly examined on team rounds with his gown removed, revealing ecchymosis spanning the patient’s back, buttocks, and posterior thighs. An urgent abdominal CT angiogram showed a large left-sided retroperitoneal hematoma. Hematology was consulted, and further workup revealed the presence of an acquired Factor VIII inhibitor. Factor Eight Inhibitor Bypass Activity (FEIBA) was initiated. The patient’s hemoglobin stabilized, and he was discharged with hematology follow up for management of his acquired factor VIII deficiency.

Discussion: Patients admitted to the hospital are often first seen and examined in the ED. Admission physical examination in the ED is often limited due to barriers such as background noise, lack of privacy, and limited space. A frontal exam is usually the most convenient approach, and further comprehensive skin examination may be deferred. In this case, evaluation for significant hemorrhage in the setting of recent trauma, coagulopathy, and acute anemia warranted a thorough physical examination for sources of bleeding. Our initial examination missed his extensive flank and lower extremity ecchymosis, which pointed to an underlying source of bleeding. This case highlights the potential of limited exams to lead to delayed diagnosis and adverse patient outcomes.

Conclusions: A thorough and appropriately-focused physical examination is the crucial first step in the evaluation of every patient presenting to the hospital, despite any existing environmental barriers.