Table of contents
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Abdominal Aortic Aneurism
- Background:
- Risk factors:
- Age ≥50 , male, smoking, white, family hx.
- Only 31% of AAA were diagnosed by physical exam.
- Screening of men > 60yo (Level C recommendation)
- As of 2014: repair recommended for AA ≥5.5cm (two large scale trials show no benefit in repairing <5.5m AAA)
- If diagnosed but no repair needed, follow once or twice/year w/ USS.
- Ultrasound and CT both 100% sensitive and specific for detection.
- Only physical exam that is useful is abdominal palpation of aorta
- Risk factors:
- How to perform:
- Patient supine, knees raised, abdomen relaxed.
- Deeply palpate aortic pulsation just few cm proximal (cephalad) to umbilicus (bifurcation).
- Examiner: both hands on abdo, index fingers on both sides of aorta. (generous amount of skin in between).
- Width of pulsation ≥2.5cm warrants further workup.
- Remember: physical exam for AAA in pts <50yo is rarely needed.
- Width of pulsation ≥2.5cm warrants further workup.
- Patient supine, knees raised, abdomen relaxed.
- Evidence:
- Finding a widened aorta conferrs a high LR+ for AAA. (Good at ruling in)
- Absence of widened aorta indicates a poor LR- (Poor at ruling out)
-
Cutoff LR+ LR- ≥ 4.0 cm 16 0.51 ≥ 3.0 cm 12 0.72 - Limits in:
- Obese patients.
- Patients that can't relax abdomen.
- If ruptured AAA or aneurism is suspected, need imaging regardless of exam. (poor at ruling out)
- Sensitivity is better when aorta can be palpated (confidence in finding results)
- I.e. palpating aorta and finding it less than 3cm is LR- of 0.30.
Congestive Heart Failure
TODO
Airflow Limitation
Taken from JAMA rational clinical exam series:
- History:
- Background Info
- Exposure to sigarette smoke (≥70 pack-yrs LR+ 8.0, never smoked LR- 0.16)
- UPDATE: >40 pak years of smoking is a single best historical feature.
- Length of smoking works as least as well as pack years (studied).
- Occupational & Environmental pollutants.
- Personal/family history of atopic diseases.
- Age: (AL is not part of normal aging process!!, but age is proxy for toxin/smoke exposure).
- Exposure to sigarette smoke (≥70 pack-yrs LR+ 8.0, never smoked LR- 0.16)
- Symptoms:
- Wheezing, coughing, sputum production.
- Sputum production ≥1/4 cup (LR+ 4)
- Wheeze(LR+ 3.8)
- (No symptom useful for ruling-in or ruling-out).
- Chronic bronchitis: sputum production for at least 3 consecutive months in at least 2 years.
- Wheezing, coughing, sputum production.
- Background Info
- Exam:
- Inspection
- Cough? (intermittent, poor k=0.29)
- Look for A-P diameter(very specific, esp in children Sp 99%)
- Vital signs:
- Pulsus Paradoxus (Sn 45%, Sp 88% - most sensitive 2nd to Match test)
- During tidal breathing, BP cuff inflated above systolic. Slowly deflate until hear sound only during expiration, continue to deflate until hear during inspiration.
- Expiration BP > Inspiration BP
- ≥15mmHg differnece = positive.
- Pulsus Paradoxus (Sn 45%, Sp 88% - most sensitive 2nd to Match test)
- Palpation
- Palpate cardiac apex (in hyperinflation apex shifts centrally). (LR 4.6 specific, not sensitive, useful if present)
- Either cannot palpate or palpate centrally in subxiphoid.
- Palpate cardiac apex (in hyperinflation apex shifts centrally). (LR 4.6 specific, not sensitive, useful if present)
- Percussion
- Hyperresonance? (very precise, and quite accurate. LR+ 4.8 LR-0.73, Sn 32% Sp94%. one of most sensitive tests).
- Diaphragmatic Excursion (normal 5-6cm, decreased in COPD)
- Auscultation
- Auscultate bilaterally over lower, middle, and upper lung fields posteriorly, anteriorly, and along mid-axillary line.
- Types of sounds:
- Wheezing - high pitched musical tones during expiration. (most precise, Sn 15%, Sp 99.6%, rules in if heard!)
- Rhonchi - Lower pitched wheeze
- Intensity of breath sounds (scoring systems are poor). (less precise k=0.30-0.63)
- Measures of airflow:
- Forced Expiratory Time:
- Take deep breath and forcefully exhale until no more air can be expelled. (keep mouth + glottis open as if yawning).
- Listen over larynx or trachea with stethoscope the duration of airflow (measure with stopwatch, record to 0.1s).
- Can do multiple measurements and average
- Results:
- <6 seconds --> decrease in likelihood of AL (LR+ 0.45)
- 6-9s --> great increase in likelihood of AL (LR+ 2.7)
- 9s --> FEV1/FVC of 70%, a level that dx an airflow limitation. (LR+ 4.8)
- Match test
- Hold burning match at 10cm from pt's widely opened mouth. If match is still burning w/ forced expiration --> positive.
- DO NOT DO if patient is on O2.
- Peak Flow Meter:
- Only useful in assessing response to therapy.
- Studies: only improved accuracy of clinical exam for 1 of 4 MDs studied. Was equivalent to auscultating a wheeze.
- Forced Expiratory Time:
- Inspection
Clubbing
- Theory: Due to a vascular shunt -> activated platelets and macrophages don't get filtered out in lungs, travel to peripheral vascular beds causing activation of growth factors etc... (intracardiac shunts, liver disease, lung disease such as bronchiectasis).
- Most common cause is bronchiectasis.
- Best Test: no best test, expertise is best!
- How to measure clubbing:
- 1. General Appearance
- 2. Nailfold angles (normal nail comes out at 160°, but in clubbing it is 180° or more.
- 3. Phalangeal Depth Ratio (Normal Distalphalangeal finger depth DPD < interphalangeal depth (IPD)
- Normal DPD < IPD
- Clubbing DPD >IPD
- 4. Schamroth Sign (Diamond)
- Very little clinical testing of this.
Thyroid Exam
- Inspection (Neck neutral or slightly extended)
- Inspect below the thyroid and cricoid cartilage
- Side: Enlargement?
- From the lateral side, you can see degree of protrusion compared to normal neck contour
- (can use ruler to measure, but hard to do).
- Indicate if gland is visible from the side.
- From the lateral side, you can see degree of protrusion compared to normal neck contour
- Front: Enlargement?
- Palpation:
- Locate thyroid isthmus by palpating between cricoid cartilage and suprasternal notch. (to left+right are the lobes)
- NOTE: approach from front/behind patient, fingers/thumbs (no data to support any, use what you like)
- Ask to relax the sternocleidomastoids of lobe palpating:
- Look in the direction of the lobe being palpated and slightly flex neck.
- UPDATE (WHO 1994): Compare volume of palpated thyroid to person's distal phalanx of thumb.
-
"Palpable thyroid"
>volume of thumb phalLR+ LR- Children 3.0 0.30 Pregnancy 4.7 0.08
-
- Comment on size:
- Categorize as "Normal" or "Goiter"
- Subcategorize into: small goiter (1-2x normal) or large goiter (>2x normal)
- "Goiter ruled out": normal thyroid, not visible with neck extended
- "Goiter ruled in": Large goiter present, or lateral prominence >2mm
- "Inconclusive": if all other findings
- Categorize as "Normal" or "Goiter"
- Notes:
- Swallowing: unknown, not studied. Most examiners do.
- Can do during inspection and/or palpation (varied)
- Theory: larynx, upper trachea, and thyroid gland move with swallowing. (give sip of water, degree of motion = size of bolus swallowed)
- Small glands are routinely overestimated and large glands underestimated (crossover at 2x normal size)
- Swallowing: unknown, not studied. Most examiners do.
Parkinson Disease
- Background
- Difficult Dx:
- Often check response to levodopa challenge. (side effects, poor Sn and Sp)
- Physical Exam the best for initial dx.
- Pathology:
- Depletion of brain stem dopaminergic neurons in the substantia nigra (they are pigmented neurons) and appearance of intracytoplasmic inclusions called Lewy bodies.
- Suspected causes: viral infections, environmental toxins, oxidative stress, heredity.
- Symptoms appear when 70-80% of dopamine is lost.
- Classic: TRAP
- Tremor at rest
- Rigidity
- Akinesia / Bradykinesia
- Postural Instability
- Most frequent misdiagnosis:
- Progressive Supranuclear Palsy
- Multisystem Atrophy (MSA) [ Includes:
- Shy-Drager syndrome
- Olivopontocerebellar atrophy
- Striatonigral degeneration
- Dementia with Lewy Bodies
- Parkinson's Disease vs. Parkinsonism:
- Parkinsonism is 2 or more of (Tremor, Rigidity, Bradykinesia)
- Parkinson Disease is a form of primary or idiopathic parkinsonism.
- Difficult Dx:
- EARLY SYMPTOMS
- Nonspecific generalized malaise, easy fatigability, subtle personality changes. (years before main symptoms).
- Other secondary manifestations:
- Disordered sleep (42%)
- Constipation (50%)
- Pain (50%)
- Depression (40%)
- Dementia (20%)
- Signs begin unilaterally --> progress asymmetrically.
- TREMOR (75% of PD patients)
- Sx:
- Usually at rest in upper extremity, visible oscillations 4-6 Hz
- Disappears during sleep and movement.
- Increases during emotional distress/anxiety.
- "Pill-rolling" quality. (index finger flexes/extends against thumb).
- Sx:
- RIGIDITY
- Involuntary stiffness of skeletal muscles.
- Electromyogram: alternating discharge pattern in opposing muscle groups (i.e. triceps+biceps)
- Resistance to movement can be smooth or interrupted.
- Cogwheeling: jerky motion of limbs as constant force is applied.
- Spasticity: selective increase in tone of flexor muscles in arms and extensor in legs (NOT in PD!)
- BRADYKINESIA
- Slowing of active movement or slowness in initiating movement.
- Initial surge of motor activity is inadequate, movements are fragmented into incremental steps.
- POSTURAL INSTABILITY
- Changes in gait and balance.
- Short, shuffling + festination.
- Loss of arm movements. (walks with arms straight down).
- Postural reflex mechanisms lost, --> pts have tendency to fall.
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)
- #1
- 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
- Increased RV diastolic pressure
- Decreased JVP differential.
- Hypovolemia (vomiting, diarrhea, diuretics, etc...)
- Position!!!!
- 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:
- No change
- Transient (few seconds) increase, >4cm and returns to former level in <10s
- 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.
- Carotid Artery Palpation
- 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.
- high-pitched sounds associated with MVP. (40-60ms after 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)
- Increases peripheral vascular resistance and increases venous return (in squatting esp.)
- Leaning forward
- Leads to increase flow away from aorta, drops afterload pressures.
- Brings out S2
- AR
- Leads to increase flow away from aorta, drops afterload pressures.
- 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
- Squatting & transient aterial occlusion (BP cuffs both arms inflated)
- 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.
- Rule In:
- 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-)
- MR vs. TR:
- 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.
- Aortic Stenosis:
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.
- Likelihood increases with following findings:
- 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
- Decreased clearance of androstenedione = increased peripheral conversion to estrogen
- 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:
| +ve LR (CI) | -ve LR(CI) |
---|---|---|
History: |
|
|
Diabetes | 2.8(1.5-4) | 0.75(0.58) |
Physical Exam: |
|
|
Terry Nails | 16-22 | 0.57-.58 |
Distended abdominal veins | 11 (2.7-44) | 0.72(0.5-0.9) |
Ascites | 7.2 (2.9-12) | 0.69 (0.59-0.78) |
Firm Liver | 3.3 (2.3-4.7) | 0.37 (0.31-0.43) |
Investigations: |
|
|
Thrombocytopenia (<160,000) | 6.3 (4.3-8.3) | 0.29 (0.20-0.39) |
Prolonged PTT/INR | 5.0 (3.2-6.9) | 0.57 (0.39-0.75) |
Albumin <3.5 | 4.4 (1.5-7.3) | 0.61 (0.41-0.81) |
Summary measures |
|
|
Overall clinical impression | 4.8(2.5-7.2) | 0.52 (0.33-0.71) |
- 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
- Elevated hydrostatic pressure and renal retention of Na and H2O
- 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.
-
- Inspection of bulging flanks (+LR2.0, -LR0.3) (DDx obesity Vs ascites)
Summary:
- To rule out ascites: no Hx of ankle swelling or increased abdominal girth, no bulging flanks, flank dullness or shifting dullness
- To make a diagnosis: positive fluid wave, shifting dullness or peripheral edema
- The puddle sign should not be performed
- 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.
- 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
- Nixon Method (Sn 59%, Sp 94%) - but BEST in 2009 update.
- 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
- Open mouth:
- 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
Dermatologic | Vascular | MSK | Neurologic | |
---|---|---|---|---|
Inspection | - Tinea pedis between toes / Fungal nail - Callous - Cellulitis - Edema | - Shiny Atrophic Skin - Bluish Skin Color (acrocyanosis) - Trophic Nail Changes - Loss of hair - Ulcers/gangrene
| - Claw Foot (subluxation of proxmal IP-MTP joints increased pressure on metatarsal heads causes claw-like toes) - Rocket Bottom Foot Collapse of arch --> replaced bony prominence) - Swollen, red ankle + foot: Charcot's foot
| - Muscle Wasting? (gastroc/quads/peroneal) - Sensory: foreign objects in shoes, Romberg, gait - Autonomic: Abnormal sweating, dry/cracked skin |
Palpation | - Temperature | |||
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