JAMA RCE Summaries

Jugular Venous Pressure

• Background:
  • Pressure and other hemodynamic events in the R atrium.
  • Estimate of central venous pressure (CVP).
  • Intravascular volume, ventricular function, valvular disease, or pericardial constriction. 
  • External jugular veins not always accurate (tortuous, valves, passes fascial planes of neck).
• Difficult assessment in patients:
  • Very low CVP
  • Mechanical ventilation
  • Short or fat necks.
  • Wide swings in CVP (i.e. asthma)
• Behaviour:
  • Pulsation drops during INSPIRATION (sudden increase in venous return to R heart).
• Cycle
  • .Three positive waves, and 3 negative troughs.  (can ausculate the heart, and palpate carotid artery, with ++experience you can distiguish them.

  • Wave	Physiology	Physical Exam
    a	RA contraction	Just before S1 and carotid pulse.
    x	RA relaxation
    c	Bulging tricuspid during isovolumentric contraction of RV (or
    x'	RA relaxation (no tricuspid bulging) (papillary muscles pull tricuspid aparatus down,  pulling open RA, increasing its volume)	(Lowest phase)
    v	Venous pooling in RA.	After aterial pulse
    y	Tricuspid opens, RA empties

  •   
• Cardiac Conditions -- JVP

  • Absence of A-wave	Atrial Fibrillation, Sinus Tachycardia
    Large CV waves	Tricuspid Regurgitation, Constrictive Pericarditis
    Slow Y Descent	Tricuspid Stenosis, Pericardial Tamponade (abscent Y descent)
    Rapid Y Descent	Constrictive Pericarditis
    Abscent X Descent	Tricupsid Regurgitation
    Large A-waves (Same as prominent X descent)	Tricuspid Stenosis, Pulmonary HTN, Pulmonic stenosis
    Canon A-waves	AV dissociation, ventricular tachycardia
    Others...	Others...

• How to Examine:
  • Position!!!!
    • Patient's head supported to relax neck muscles.
    • Bed is inclined to bring the top of the JVP column below jaw and above clavicle.
      • (If bed too low, JVP may be above jaw)
      • (If bed too high, JVP may be below clavicle)
    • Often requires 30-45° above horizontal.
      • If JVP elevated, often need above 45°
    • Tangental light improves detection!
  • Distinguishing carotid from jugular pulsations:
    • #1
      • JVP is diffuse, two waves, and upward deflection is slow.
      • Carotid is fast, well-localized, single, outward deflection.
    • #2
      • JVP varies with position. (unless extremely high) It disappears below clavicle when pt is upright or above angle of jaw when lies flat.
      • Carotid do not vary with position
    • #3
      • JVP varies with inspiration (unless intrathoracic disease).  (Descendes with inspiration)
      • Carotid does not vary with respiratory cycle (except if pulsus paradoxis)
    • #4
      • JVP is non-palpable and occludable. Applying pressure above clavicle will obstruct the vein, fill its distal segment, and pulse disappears.
      • Carotid almost always palable
    • #5
      • JVP responds to hepato-jugular-reflux. (even if it's normal)
  • Estimation of CVP  (Normal 5cm of H2O - 9cm of H2O)
    • Important note: Angle of Louis is 5cm above R-atrium, and clavicle is 2cm above angle of Louis at 45°.
    • Level of JVP is the HIGHEST point of oscillation (with expiration).  
    • Landmark for 0 is angle of Louis (5cm above R-atrium).
      • Therefore: JVP is 5cm less than CVP.
    • At 45° angle: clavicle is 2cm above sternal angle (CVP over 7mm can be observed).
    • Normal CVP is 5cm, JVP is at sternal angle (2cm below first visible point)..
      • Therefore: Cannot see normal JVP at 45°, must be horizontal.
    • Upper limit of normal JVP is 9cm of H2O  (produces a JVP of 4cm ASA).
  • Elevated JVP differnetial:
    • Represents increase in CVP:
    • DDx:
      • Increased RV diastolic pressure
        • RV failure / infarction
        • Pulmonary HTN
        • Pulmonic stenosis
      • Obstruction to R-ventricular flow
        • Tricuspid stenosis
        • R-atrial myxoma
        • Constrictive pericarditis
      • Hypervolemia
      • SVC obstruction
  • Decreased JVP differential.
    • Hypovolemia (vomiting, diarrhea, diuretics, etc...)
• Hepatojugular Reflux
  • Test used to determine RV failure or reduced RV compliance
  • Technique
    • Instruct patient to breathe through open mouth (no valsalva)
    • Apply firm pressure to mid abdomen 15-30s (20-35mmHg)
  • Healthy people exhibit one of three responses:

1. No change
2. Transient (few seconds) increase, >4cm and returns to former level in <10s
3. Sustained increase of >3cm sustained through entire compression

• Positive test: sustained increase of ≥4cm.

• Kussmaul Sign
  • JVP normall decreases with inspiration.
  • Positive Kussmaul: Paradoxic increase in JVP height during inspiration.
  • Mechanism:
    • Inspiration decreases intra-thoracic pressure --> R-side of heart cannot accommodate increase in venous return.
  • Positive in:
    • Constrictive paricarditis (classically)
    • Severe R-sided heart failure
    • Myocardial restrictive disease (amyloidosis, tricuspid stenosis, SVC syndrome)

Systolic Murmurs

• Causes of systolic murmurs:
  • Cardiac Structural (AS, HCM, MR, VSD, PS, TR, ASD)
  • Non-Cardiac - increased flow (Anemia, Thyrotoxicosis, Sepsis, Renal failure w/ overload).
• Palpation:
  • Carotid Artery Palpation
    • Pay attention to peak.
    • Normal: Sharp Tap.  
    • Abnormal: Nudge.
    • Normal Volume: easily felt with light palpation.
    • Reduced Volume: difficult even with firm palpation.
  • Apical-Carotid Delay
    • Palpate precordial apex and carotid
    • Abnormal: any delay.
  • Brachioradial Delay
    • On R arm --> Put R thumb on brachial artery, and L index+middle fingers on radial a. 
    • Abnormal: any palpable delay.
• Auscultation
  • Murmur: any sound that is longer than a heart sound.

  • Grade 1	Not heard immediately, but only after focused on systole a few secs.
    Grade 2	Heard immediately on ausc, and NOT LOUD
    Grade 3	Heard immediately on ausc, and LOUD
    Grade 4	Palpable precordial thrill (+ LOUD murmur)
    Grade 5	Heard without auscultation

  • S2: normal decreased or absent.
    • 2nd right or left intercostal spaces next to sternum, louder than S1 in this area.
    • Abnormal splitting has not been evaluated.
  • S4: abnormal pre-systolic sound
    • Heard with bell at the apex of patient in L-lateral decubitus position
  • Systolic clicks (aka non-ejection clicks)
    • high-pitched sounds associated with MVP. (40-60ms after S1).
      • When pt stands --> click moves closer to S1.
  • Ejection sounds (aka ejection clicks)
    • Aortic and pulmonary valves opening in early systole.
    • No change with patient position.
• Types of manouvers:
  • Squatting & transient aterial occlusion (BP cuffs both arms inflated)
    • Increases peripheral vascular resistance and increases venous return (in squatting esp.)
      • Leads to ventricular underfilling
      • Increases L-sided regurgitant murmurs.
        • AR
        • MR
        • VSD
      • Decreases:
        • HOCM (overfill ventricle, stent it open)
  • Leaning forward
    • Leads to increase flow away from aorta, drops afterload pressures.
      • Brings out S2
      • AR
  • Passive Leg Elevation & Standing-->Squatting Manouvre
    • Increases venous return, overfills ventricle, stents HOCM open, removes murmur.
    • Decreases or unchanged:
      • HOCM
  • Standing
    • Less venous return, ventricle collapses, causing HOCM obstruction.  (MVP, less pressure holding prolapsed valve).
    • Decreases all murmurs except:
      • HOCM
      • MVP
• Types of pathology and murmurs:
  • Aortic Stenosis:
    • Rule In:
      • Effort Syncope
      • Slow increase in carotid pulse.
      • Decreased intensity or absent S2.
      • Apical-Carotid delay
      • Brachioradial delay
    • Rule Out:
      • Absense of systolic murmur.
      • Lack of radiation to R carotid artery.
    • Useful in combination:
      • Decreased carotid volume.
      • Delayed carotid upstroke.
      • Decreased/absent S2.
      • Murmur loudest at 2nd R intercostal
      • Calcifications on CXR.
  • Mitral Regurgitation:
    • Note: non-cardiologist assessment of MR is much less accurate  (medical students are better LR+ 4.4), house staff are worst.
    • Rule in:
      • Mitral valve murmur (mid-to-L thorax) 5th interspace.
      • Late systolic or holosystolic murmur.
    • Rule out:
      • Absence of mitral-area murmur (EXCEPT IN ACUTE MI!)  Murmur can be absent.
    • Other important ones:
      • Transient arterial occlusion  (for MR and VSD)
  • Tricuspid Regurgitation
    • MR vs. TR:
      • Increased murmur intensity on inspirtation (INFINITY LR+, and 0.20 LR-)
      • Increased murmur intensity with sustained abdo pressure (INFINITY LR+, 0.33 LR-)
  • HOCM (hypertrophic subaortic stenosis)
    • Decreased murmur intensity with passive leg elevation. (LR+ 8.0, LR- 0.22)
    • Decreased or unchanged murmur itensity with standing --> squatting. (LR+ 4.5, LR- 0.13)
  • Mitral Valve Prolapse (MVP)
    • Systolic click (with or without systolic murmur) is sufficient diagnosis.
    • Absence of both systolic click and murmur --> MVP unlikely.

Stroke

• Among non-comatose patients without head trauma who have neurologically relevant sympsoms for which a stroke is a consideration, prior probability of a TIA or stroke is approximately 10%.  (important for pretest probability)
  • Likelihood increases with following findings:
    • Facial Droop
    • Arm Drift
    • Speech disturbance.
  • Simple clinical rules (CPSS and LAPSS) can increase odds.
• However: appropriate neuroimaging or other tests are still required to diagnose stroke and/or other neurological pathology.
• Notes:
  • Reliability is lowest for historical items and subjective findings (sensory exam).
  • Reliability is higher for motor findings.
• NIH Stroke Scale is useful for defining severity of stroke.  Reliability improves with experience and online training (free from NIH). 
• 
  

  Pre-Hospital Stroke Evaluation:  Taken from the NIH Stroke Scale, as most useful findings, and assembled Into a Prehospital Stroke Scale:  Cincinnati Prehospital Stroke Scale (CPSS)       Findings No of Findings LR+ (95% CI) 1. Facial paresis 2. Arm Drift 3. Abnormal speech 3 14 2 4.2 1 5.2 0 0.39   (findings relatively similar in physicians and emerg medical personnel

• Hospital Stroke Evaluation   Findings # of Findings LR+ (95% CI) 1. Persistent neurological deficit 2. Focal Neurological Deficit 3. Acute onset of symptoms during previous week. 4. No head trauma 4 40 1-3 Uncertain, but probability of stroke ~ ≥ 10% 0 0.14

• Another stroke scale (two above more common):

  • Los Angeles Prehospital Stroke Screen (LAPSS)      1. Unilateral arm drift.      2. Handgrip strength.      3. Facial paresis. Unilateral deficit in one of three = POSITIVE.   Sensitivity 91%, Spec. 97%. LR+: 31, LR-: 0.09   Lots of exclusions: (noncomatose, nontrauma, sx compatible with sroke). Also: >45, no seizure hx, sx <24hrs, not wheelchair or bedridden, and BG 3.3--22 mmol/L

Cirrhosis

• Why is this important?
  • Endoscopic screening for varices, for HCC, for encephalopathy and for SBP and consideration for transplant
  • ~10-17% of patients with unexplained elevated aminotransferases have previously unsuspected cirrhosis
• Pathophysiology
  • Decreased clearance of androstenedione = increased peripheral conversion to estrogen
    • Palmar erythema
    • Spider nevi
    • Gynecomastia
    • Decreased body hair
    • Testicular atrophy
  •  Loss of function
    • Jaundice
    • Hypoalbuminemia
    • Decreased II VII IX X (also due to cholestasis and decreased Vit K)
  • Portal HTN (Portal venous pressure gradient >10mmHg)
    •  Splenomegaly, Hypersplenism + Thrombocytopenia
    • GE varices
    • Edema, ascites
    • Hepatic encephalopathy
• Symptoms and signs
  • See other RCE for: Examination of the liver, spleen, detection of ascites and clubbing.
  • Jaundice: examine sclera under natural light or mucosa below the tongue (bili >40)
  • Terry nails
  • Palmar erythema
  • Gynecomastia (true breast glandular tissue)
  • Spider nevi (in SVC territory >2-3)
  • Facial telangiectasias
  •  Caput medusa àabdominal wall veins – determine flow:
    • Away from umbilicus = portal HTN
    • IVC obstruction = flow towards SVC
    • SVC obstruction= flow towards IVC
  • Asterixis

Evidence summary:

• Signs:
  • +ve LR: Distended abdominal veins, ascites and spider nevi = most cited with +ve LR >4. Ascites and spider nevi may be the most reliable (narrow CI)
  • -ve LR: not as reliable however lack of a firm liver or hepatomegaly were in 3 studies with –ve LR less than 0.4
• Laboratory investigations:
  • Best test:Thrombocytopenia plt<160*10^3
  • +ve LR:Prolonged PTT/INR, albumin<3.5
• Overall clinical impression: +ve LR 4.8, -ve LR 0.52, narrow CI

SUMMARY:

• Best +ve LR: Hx of diabetes, ascites on PE, plt <160,000
• Best –ve LR: absence of hepatomegaly or firm liver and plt >160,000
• Notably Hx of alcohol use is not useful
• Overall clinical impression and scoring indices may be more beneficial than individual laboratory tests such as plt count, transaminases and INR.

Ascites

Background

• Why is this import to answer with a clinical exam?
  • May indicate CHF, liver diease, nephrotic syndrome, or malignancy or raise suspicion for SBP
  • USS can detect 100cc in abdomen (gold standard)
• Pathophysiology
  • Elevated hydrostatic pressure and renal retention of Na and H2O
    • ​Cirrhosis, CHF, Constrictive pericarditis, IVC obstruction, Hepatic vein occlusion
  • Loss of oncotic pressure with inadequate protein synthesis/wasting
    • ​Nephrotic syndrome, protein-losing enteropathy, malnutrition, cirrhosis or hepatic insuficiency
  • Infection/malignancy 
• How to elicit symptoms and signs
  • Hx: liver disease (+LR 3.2) or CHF (+LR 2.0)
  • Sx: ankle edema (+LR 4.2, -LR0.10), weight gain (+LR3.2), change in abdominal girth (+LR 2.8 -LR 0.17)
  • Signs - all have good inter-observer agreement:
    • Inspection of bulging flanks (+LR2.0, -LR0.3) (DDx obesity Vs ascites)
      • most sensitive
    • Percussion for flank dullness (+LR 2.0 -LR0.3)  and shifting dullness (+LR 2.7 -LR0.3)
      • Percuss from umbilicus towards flanks, tympanic centrally due to bowel loops filled with gas floating above the ascites
      • Roll the patient away from the examiner onto lateral recumbant position, now the area of dullness shifts to the dependent side.

    • 

    • Test for fluid wave (+LR6.0, -LR 0.8)
      • assistant or patient places medial edges of hands firmly across centre of abdomen to block transmission through subcutaneous fat
      • Examiner taps flank fharply while using the fingertips to feel for an impuse on the opposite flank.

        • 

Summary:

1. To rule out ascites: no Hx of ankle swelling or increased abdominal girth, no bulging flanks, flank dullness or shifting dullness
2. To make a diagnosis: positive fluid wave, shifting dullness or peripheral edema
3. The puddle sign should not be performed
4. Because USS can detect such small amounts of ascites not elicited by clinical examination the absence of an physical signs does not rule out the presence of peritoneal fluid.
5. Patients should not be evaluated for ascites during the general physical exam unless
   • Hx of Cirrhosis, CHF, Constrictive pericarditis, nephrotic syndrome, malnutrition or chronic diarrhea, neoplastic disorders, systemic infectious disease, blunt abdominal trauma.

Splenomegaly

• Background
  • Splenomegaly in adults require explanation. (infections, cancers, connective tissue disorders, nonspecific).
• Anatomy:
  • Shaped curved wedge follows along the 10th rib.
  • Lies between the L-side of diaphragm, anterior axillary line, stomach, L-kindey.
  • Maximum dimensions:
    • Length 12cm
    • Width: 7cm
    • Cephalo-caudad diameter ≥13cm.
  • Normal spleen cannot be palpated. (Lies within the rib cage).
• Inspection
  • LUQ of abdomen for bulging mass descending on inspiration. (non-specific, rarely distorts abdomenal wall)
• Percussion
  • Dullness to percussion is key! (impinges on adjacent air-filled lung, colon, stomach)
  • Three methods:
    • Nixon Method  (Sn 59%, Sp 94%) - but BEST in 2009 update.
      • Patient in R-lateral decubitus position.
      • Start percussion midway along left costal margin --> percuss up perpendicular to costal margin.
      • Positive if percussion >8cm above costal margin (stomach creates initial dullness). 
    • Castell Method (Sn 82%, Sp 83%) - but WORST in 2009 update
      • Patient supine.
      • Percuss lowest intercostal space anterior-axillary line during bost expiration + inspiration.
      • Positive if percussion is dull or becomes dull on inspiration.
    • Traube Space (Sn 62%, Sp 72%) - SECOND BEST in 2009 update
      • Supine with left arm slightly abducted to reveal Traube's space.
      • Space marked by: 6th rib, mid-axillary line, L-costal margin.
      • Percuss across ≥ 1 levels from medial-to-lateral.
      • Positive if dull to percussion.
      • NOTE: False-negatives with obesity, False-positives with recent food intake
• Palpation:  (Sn 27%, Sp 98%)
  • (NOTE: Recommended palpation only if percussion is DULL.  If not dull (normal), then palpation will not be helpful due to low sensitivity, but that was revised in 2009 update).
  • Method 1 (Two-Handed Palpation):
    • Patient in R-lateral decubitus.
    • Examiner's L-hand behind the thorax (lower rib cage) lifting the lowermost ribcage anteriorly and medially
    • Examiner's R-hand tips of fingers just beneath the L-costal margin.
    • Patient asked to take long, deep breath, and examiner palpates spleen.
      • If not palpated, move R-hand down 2cm towards umbillicus... repeat until confident no large spleen.
  • Method 2 (One-Handed Palpation)
    • Same as 2-handed palpation, except no counter-pressure.
  • Method 3 (Hooking Maneuver of Middleton)
    • Patient supine flat with L-fist under L-costovertebral angle.
    • Examiner to patient's L-side, both hands curled under L-costal margin, palpating with every breath.
  • NOTE: Impossible to get above upper border of spleen, if you can, suspect a mass.
     
• GOLD STANDARD: Scintigraphy, or ultrasonography.
   
• 2009 UPDATE:
  • New studies with CT imaging.

  • Maneuver	LR+	LR-
    Percussion--------------
    Nixon Sign	3.6	0.41
    Traube's Space	2.3	0.48
    Castell Sign	1.2	0.45
    Palpation----------------
    Supine, 1-handed	8.2	0.41
    Middleton Hooking	6.5	0.16

• Summary of Update:
  • Palpation is better than previously thought.
  • Traube's Space is better, Nixon is the best.

Obstructive Sleep Apnea

Based on Thiwanka's presentation, but needs to be updated with JAMA RCE article... (TODO!)

• Before beginning:
  • Weight, Height, calculate BMI
  • Vital signs (regular/irregular pulse), BP as complication.
• Inspection:
  • Hypoxia? (central, peripheral)
  • Distribution of body fat (in trunk = higher risk).
  • Face deformities (macrognathia, micrognathia)
• Palpation: (head to toe)
  • Open mouth:
    • Tongue: Macroglossia?
    • Airway: Soft tissue masses?  Malampatti Score 1-4.
  • Neck:
    • Measure neck circumference
    • Thyromental distance 
    • .... distance
• Cardiac examination  (for complications: HTN, LVH, Afib, pulmonary HTN)
  • Palpate PMI (sustained? lateral?)
  • Palpate RV heave, pulmonic pulsations.
  • Auscultate (paradoxically split S2 [HTN], loud P2 [pulm HTN]
  • Murmurs (TR? pulmonary)
• Signs of R-heart failure (complication)
  • JVP? (TR findings?)
  • Abdominal/sacral edema.
  • Pedal edema.

Diabetic Foot

• Approach:
  • Dermatologic
  • Vascular
  • Musculoskeletal
  • Neurologic