Accurate Physical Examination Research Articles

Restless legs syndrome: differential diagnosis and management with rotigotine

RLS is a common sleep disorder with distinctive clinical features. The prevalence of RLS in Caucasians and North Americans ranges from 5% to 10%. However, only some of these subjects (almost the 3% of the general population) report being affected by a frequent and severe form of the sleep disorder. RLS is diagnosed clinically by means of four internationally recognized criteria that summarize the main characteristics of the sleep disorder. Besides the essential criteria, supportive and associated features of RLS have been established by experts in order to help physicians treat patients with doubtful symptoms. Several clinical conditions may mimic this sleep disorder. In order to increase the sensibility and specificity of RLS diagnosis, doctors should perform a meticulous patient history and then an accurate physical and neurological examination. Dopamine agonists are recognized as the preferred first-line treatment for RLS. Rotigotine is a non-ergoline dopamine agonist with selectivity for D1, D2 and D3 receptors. The drug is administered via transdermal patches which release rotigotine for 24 hours. Four clinical trials demonstrated that this compound is able to improve RLS symptomatology with few and moderate adverse events. Head to head trials are required to compare the efficacy and tolerability of rotigotine with other dopamine agonists administered via oral intake. Rotigotine has been approved by the FDA and EMEA for Parkinson's disease. For the treatment of moderate to severe idiopathic RLS, rotigotine has been recommended for approval by the EMEA and is under review by the FDA.

Ultrasound of the peripheral nerves

Peripheral nerves disorders are common in the rheumatologic practice and can mimic a variety of musculoskeletal diseases. Clinical evaluation remains the mainstay for diagnosing nerve disorders of the extremities. A careful history and an accurate physical examination lead in most patients to a high diagnostic suspicion. Nevertheless several imaging techniques are usually obtained to confirm the clinical data and in the preoperative workup. Although standard radiographs and computed tomography do not visualize the nerves directly, they can reveal the adjacent anatomic structures such as bones and joints and can add additional information that frequently is essential in the choice of adequate treatment. Magnetic resonance imaging and ultrasound show peripheral nerves directly and can reveal their size and internal structure. With the new developments in high resolution, electronic broadband transducers, ultrasound (US) is now considered an optimal imaging technique to evaluate the normal anatomy and disorders of peripheral nerves. Well recognized advantages of this technique in this field are: the possibility of realizing a dynamic examination and assessing long nerves segments in a short time; it is non-invasive and low cost. In addition US is better accepted by the patients. In this article we present a brief description of the normal and US anatomy of the peripheral nerves followed by a description of the US appearance of the most frequent disorders: entrapment neuropathies (EN), tumor and cystic lesions.

Current concepts in the evaluation and management of syncope

Syncope is a very common presentation with a wide differential diagnosis and equally wide prognostic implications. Recent work has highlighted the importance of an accurate history and physical examination as the basis of diagnosis, prognosis, and treatment. Several centers have evaluated the role of structured histories and comprehensive syncope evaluation guidelines and units in managing syncope. Although these do provide comprehensive care, whether they improve overall outcome and reduce costs is far from clear. This is partly because there are few effective treatments for the major cause of fainting, vasovagal syncope. Recent randomized trials have highlighted the roles of physical counterpressure maneuvers and midodrine and the limitations of treatment with beta blockers and permanent cardiac pacing.

Transient Ischemic Attack: Definitions and Clinical Presentations

The definition of transient ischemic attack has changed from a focal, neurologic event that lasts less than 24 hours to one that typically lasts less than 1 hour and is not associated with changes on neuroimaging. Transient ischemic attacks, using the older definition, carry a 10% risk of stroke within 90 days and are therefore considered a serious condition meriting urgent attention. The manifestations of transient ischemic attacks are varied and include events that involve the anterior and posterior cerebral circulations. Correct diagnosis depends on an accurate medical history and physical examination, combined with the appropriate neuroimaging. It is uncommon that syndromes such as syncope, isolated dizziness, drop attacks, or global amnesia are caused by cerebral ischemia or transient ischemic attack. With the careful evaluation of symptoms according to this definition of transient ischemic attack, a clinician can determine whether a transient ischemic attack has occurred and thus propose treatment that may decrease the likelihood of a subsequent stroke.

Dengue and Chikungunya viruses in blood donations: risks to the blood supply?

Dengue and Chikungunya viruses in blood donations: risks to the blood supply?

Understanding the Dialysis access Steal Syndrome. A Review of the Etiologies, Diagnosis, Prevention and Treatment Strategies

Distal hypoperfusion ischemic syndrome (DHIS), commonly referred to as hand ischemia or 'steal' after dialysis access placement, occurs in 5-10% of cases when the brachial artery is used, or 10 times that of wrist arteriovenous fistulas (AVFs) using the radial artery. It is typically seen in elderly women with diabetes, and may carry severe morbidity including tissue or limb loss if not recognized and treated. Three distinct etiologies include (1) blood flow restriction to the hand from arterial occlusive disease either proximal or distal to the AV access anastomosis, (2) excess blood flow through the AV fistula conduit (true steal), and (3) lack of vascular (arterial) adaptation or collateral flow reserve (ie atherosclerosis) to the increased flow demand from the AV conduit. These three causes of steal may occur alone or in concert. The diagnosis of steal is based on an accurate history and physical examination and confirmed with tests including an arteriogram, duplex Doppler ultrasound (DDU) evaluation with finger pressures and waveform analysis. Treatment of steal includes observation of developing symptoms in mild cases. Balloon angioplasty is the appropriate intervention for an arterial stenosis. At least three distinct surgical corrective procedures exist to counteract the pathophysiology of steal. The ultimate treatment strategy depends on severity of symptoms, the extent of patient co-morbidity, and the local dialysis access technical team support and skills available.

Die Schwangere mit neurologischen Begleiterkrankungen - Implikationen für das peripartale Anästhesiemanagement - Teil I

In the parturient as well as in the pregnant patient with neurological disease, surgery is necessary more frequently than in healthy pregnants. Most pregnancies of these patients will result in a slightly increased rate for cesarean section. The focus of anesthesia care is mostly to avoid damage to the fetus, in some pathologies to protect the mother. Pregnancy itself may change the course of pre-existent chronic neurological diseases such as epileptic seizure, multiple sclerosis, or myasthenia gravis. Other diseases will have their onset predominantly in pregnancy such as back pain, nerve compression syndromes, some brain tumors or cerebrovascular events. Subarachnoidal hemorrhage and intracranial bleeding contribute to 65 % of maternal mortality. Finally, pregnancy induced conditions such as eclampsia and HELLP syndrome and its management are reviewed where the concerns for the nervous system have high relevance for anesthesiological management. Anesthesia care for the pregnant and the parturient presenting with a neurological disease requires 1.) expertise with neuroanesthesia and obstetric anesthesia care, 2.) accurate physical examination of the neurological system preoperatively, 3.) safe choice and conductance of the anesthesia technique (mostly regional anesthesia) 4.) avoidance of unfavorable drug effects for the fetus and the nervous system of the mother and 5.) intraoperative neuromonitoring together with the control of the fetal heart rate.

Evaluation and Treatment of Zygomatic Fractures

Orbitozygomatic fractures are some of the most common facial fractures evaluated and treated by plastic surgeons. A considerable debate remains surrounding the manner of evaluation and appropriate treatment modalities. On the one hand, some would suggest that few fractures need formal open reduction and internal fixation, whereas others would argue that the pull of the strong masseter muscle ultimately leads to inferior and lateral rotation of the zygoma, which justifies open reduction and internal fixation of most fractures excepting those fractures that are nondisplaced at all points of articulation. The authors hope to shed some light on these issues by conveying their perspective on these fractures that has developed over several decades while servicing a single, major Level I trauma center. In general, the authors feel that through a detailed evaluation including an accurate physical examination of the face and orbit combined with detailed computed tomographic scanning of the craniofacial skeleton and soft tissues, an appropriate treatment plan can be generated. The common goal among all treatment plans should be the exact three-dimensional restoration of the disturbed anatomy, that is, anatomical reduction and the need for accurate restoration of orbital anatomy and volume when necessary.

The Gastroenterology Core Curriculum, Third Edition

The Gastroenterology Core Curriculum, Third Edition

Correlation between urodynamics and perineal ultrasound in female patients with urinary incontinence

We performed urodynamics and perineal ultrasound in female patients with urinary incontinence to assess morphology and function of the bladder base-urethra complex and of the detrusor muscle, and to find the correlation between these investigations in the diagnosis of (a) bladder neck and urethral hypermobility and (b) detrusor overactivity; we wanted to compare the tolerabililty of the urodynamic investigation and of the perineal ultrasound. We considered 66 female patients referred to our outpatient clinic for urinary incontinence; we also studied 14 healthy control patients. After accurate case-history collection and physical examination, urodynamic investigation and perineal ultrasound were performed, with recording of parameters specific to both investigations. The statistical analysis was performed by ANOVA, Bonferroni post hoc test, and Spearman correlation test. The tolerability index between the diagnostic investigations performed was assessed by a 3-point scale suggested by the patient. In patients with stress incontinence the posterior urethro-vesical angle, the angle of urethral inclination, and the proximal pubo-urethral distance are significantly different under stress compared to the resting phase; in patients with urge incontinence, the detrusor wall is thicker and is accompanied by an increase in opening detrusor pressure and detrusor pressure at maximum flow; it is also accompanied by detrusor overactivity with increased urethral functional length. Increased urethral functional length is suggested on axial US images by alteration of its normal characteristic target-like appearance with four concentric rings of different echogenicity. In all cases the tolerability of perineal ultrasound has been higher than that of urodynamics. There is a good correlation between urodynamic and perineal ultrasound in the diagnosis of bladder neck and urethral hypermobility; perineal ultrasound can also be useful in the diagnosis of urge incontinence. Functional compressive urethral obstruction can be diagnosed on the basis of the ultrasound aspect of the urethral sphincter.

Babesiosis masquerading as recurrent immune thrombocytopenic purpura in a splenectomized patient

Dear Editor, Splenectomy is a clinically effective therapeutic intervention against chronic immune thrombocytopenic purpura (ITP) [1]. Severe, potentially life-threatening infections are a major long-term complication of splenectomy [2]. Certain infections may present with thrombocytopenia, which, in the case of splenectomized patients with a history of ITP, may be mistaken for ITP recurrence. We report what is, to the best of our knowledge, the first case of babesiosis in a patient with stable chronic ITP who had previously undergone splenectomy. The patient was a 66-year-old woman from Nantucket Island, MA, USA, with a known diagnosis of ITP, who was treated with prednisone, intravenous immunoglobulin, and rituximab before eventually undergoing splenectomy. Her postsplenectomy platelet count remained stable in the 60,000–70,000 range, without treatment. Two years following splenectomy, she presented with fever (temperature 101°F), chills, myalgias, and arthralgias. She denied any bleeding or bruising. Physical examination was unremarkable. Complete blood count demonstrated a hematocrit of 45.5 vol%, a white blood cell count of 4,600 cells/μL, and a platelet count of 10,000 platelets/μL. Liver function tests were notable for a slightly elevated alanine transaminase of 64 and aspartate transaminase of 49. Peripheral smear showed characteristic Howell-Jolly bodies and rare intraerythrocytic parasite ring forms in normal-sized red blood cells (Fig. 1). Babesiosis was confirmed by extremely high IgG and IgM titers to Babesia of 1:1,024 and 1:1,280, respectively, and a positive polymerase chain reaction (PCR). Importantly, there were no detectable antibodies for Lyme disease and ehrlichiosis. The patient was started on azithromycin and atovaquone and on a tapering dose of prednisone. She received 4 weeks of antibiotic therapy and her platelet count increased to 325,000 platelets/μL. Four weeks after completing the course of antibiotics, the platelet count dropped again to 24,000 platelets/μL. She continued to have circulating intracellular parasites on peripheral smear, and Babesia PCR and serologies were still positive. Atovaquone, azithromycin, and prednisone treatments were restarted. Her platelet count steadily improved, and only after 4 months of antibiotic therapy did the PCR for Babesia normalize. Steroids were discontinued. Her platelet count returned to her baseline value of 60,000–70,000, off immunosuppressive and anti-infective therapies. The approach to thrombocytopenia should always include an accurate history, physical examination, and examination of the peripheral blood smear. Splenectomy predisposes to infections that may present with thrombocytopenia, including ehrlichiosis, Colorado tick fever, Rocky Mountain spotted fever, babesiosis, and malaria. While patients can have a recurrence of ITP, other causes of thrombocytopenia need to be excluded. Babesiosis is a worldwide tick-borne disease caused by the intraerythrocytic protozoan Babesia [3]. Humans are infected by various tick vectors (Ixodes scapularis and Ixodes ricinus) and rarely by transfusions. In the USA, endemic areas include the islands off the coasts of MA and NY [4]. Symptoms include fever, chills, weakness, and myalgias. Babesiosis may present with hemolytic anemia, lymphopenia, and thrombocytopenia. Splenectomized patients may develop a fulminant infection with massive intravascular hemolysis [5]. The peripheral blood smear reveals small coccoid and dumbbell-shaped organisms. The trophozoites are small rings similar to those of Plasmodium falciparum. The parasites can be pyriform (pear shaped). Babesia microti is associated with Maltese cross forms and ring forms. IgM or P. A. Konstantinopoulos . K. B. Miller . B. J. Dezube (*) Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA e-mail: bdezube@bidmc.harvard.edu Tel.: +1-617-6677082 Fax: +1-617-9758030

Subscapularis Tendon Tears

Pathology of the subscapularis tendon is both infrequently identified and not commonly considered as a major source of shoulder pain and dysfunction. Subscapularis tendon pathology can present as isolated tears; partial-thickness tears; anterosuperior tears, also involving the supraspinatus tendon; complete rotator cuff avulsion; and rotator interval lesions, in which instability of the long head of the biceps tendon may dominate the clinical presentation. Although an accurate physical examination is paramount, modalities such as arthroscopy, magnetic resonance imaging, and ultrasound have advanced knowledge of the spectrum of abnormalities involving the subscapularis tendon. Nonsurgical management may be effective for most partial tears. Surgically, open repair is more frequent than use of arthroscopic techniques. Tears of the subscapularis tendon portend a different prognosis than do supraspinatus tendon tears, especially when the injury is acute and diagnosis is delayed.

Immunohistochemical Evaluation of VEGF Inflamed Cystic Radicular Lesions and in Keratocysts

Vascular Endothelial Growth Factor, also known as Vascular Permeability Factor, is a multifunctional cytokine hyperexpressed during angiogenesis and in numerous physiological and pathological processes characterised by an increase of vascular permeability. The aim of this study was to evaluate the angiogenetic processes which are accompanied by an expansion of cystic radicular lesions and of keratocysts of the jaw bone. 12 subjects were chosen with an average age of 43 years, of whom 8 were males and 4 females. After an accurate history and physical examination, the patients underwent surgery for removal of the cysts. The samples taken were histologically and immunohistochemical examined. The histological exam confirmed the diagnosis of radicular cysts and keratocysts. The immunohistochemical examinations were positive for VEGF in all the lesions analysed, even though they had different immunostaining. Using a semi-quantitative method, in the radicular cyst samples it was possible to highlight a wider expression of the vascular component, both in the inflamed area and the adjacent stroma. The lesions with keratin content showed newly formed and modest vascularisation both in the area showing slight inflammation, where the cellular component was prevalent, and in the adjacent areas showing no inflammation. Therefore, angiogenesis could take on a primary role in the development of cystic lesions of the jaw. However, the differences of expression of the VEGF protein suggest the need for wider monitoring to better evaluate a possible use of such a protein as a diagnostic marker.

Hyponatraemia for the clinical endocrinologist

Hyponatraemia for the clinical endocrinologist

Physical Examination of the Carpal Bones by Orthopaedic and Accident and Emergency Surgeons

Our aim was to test knowledge of carpal bone surface anatomy among orthopaedic and accident and emergency surgeons. A survey of 58 surgeons was conducted. Each was asked to palpate seven points on five commonly injured carpal bones. Eight surgeons declined to participate. Five of the remaining 50 correctly palpated all surface markings. Six failed to accurately palpate even a single point. The scaphoid waist and trapezial ridge were accurately palpated by 47 surgeons. The median score for all participants was 3 correctly identified points. The majority of orthopaedic and accident and emergency surgeons do not perform an accurate physical examination of the carpal bones. The ancient art of history taking, precise physical examination and elucidation of a confident diagnosis is at risk of being replaced with tentative diagnoses and imaging techniques that are expensive and time consuming. We believe that basic anatomical teaching is inadequate.

Diaphragmatic Paralysis after Endovascular Stent Grafting of a Thoracoabdominal Aortic Aneurysm

Diaphragmatic Paralysis after Endovascular Stent Grafting of a Thoracoabdominal Aortic Aneurysm

The “Moving Valgus Stress Test” for Medial Collateral Ligament Tears of the Elbow

Background The diagnosis of a painful partial tear of the medial collateral ligament in overhead-throwing athletes is challenging, even for experienced elbow surgeons and despite the use of sophisticated imaging techniques. Hypothesis The “moving valgus stress test” is an accurate physical examination technique for diagnosis of medial collateral ligament attenuation in the elbow. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods Twenty-one patients underwent surgical intervention for medial elbow pain due to medial collateral ligament insufficiency or other abnormality of chronic valgus overload, and they were assessed preoperatively with an examination called the moving valgus stress test. To perform the moving valgus stress test, the examiner applies and maintains a constant moderate valgus torque to the fully flexed elbow and then quickly extends the elbow. The test is positive if the medial elbow pain is reproduced at the medial collateral ligament and is at maximum between 120 ° and 70 °. Results The moving valgus stress test was highly sensitive (100%, 17 of 17 patients) and specific (75%, 3 of 4 patients) when compared to assessment of the medial collateral ligament by surgical exploration or arthroscopic valgus stress testing. The mean shear range (ie, the arc within which pain was produced with the moving valgus stress test) was 120 ° to 70 °. The mean angle at which pain was at a maximum was 90 ° of elbow flexion. Conclusions The moving valgus stress test is an accurate physical examination technique that, when performed and interpreted correctly, is highly sensitive for medial elbow pain arising from the medial collateral ligament.

Pediatric Spinal Cord Injury

Significant differences exist in the anatomy and biomechanics of the pediatric spine in comparison to the adult spine. These unique anatomical characteristics and behavioral differences predispose the developing child to unique spinal injury patterns. These differences must be considered when managing spinal and spinal cord injuries (SCIs) in the pediatric population. Children less than 8 years of age are more prone to upper cervical spine injuries. After this, the maturational growth and development with regard to spinal anatomy reflect the transition to injury patterns characteristic of the adult patient. Although the prevalence of SCIs is lower in children, diagnosing subtle spinal injuries is often more difficult. This is especially true in light of the often unappreciated radiographic differences between an immature and mature spinal axis and the difficulty in obtaining an accurate physical examination in the child. The increased healing potential of the pediatric osteoligamentous structures represents another important and unique characteristic of the immature spine. Nonoperative strategies using various forms of external immobilization for injury patterns requiring surgical intervention in the adult may often be used with success in the pediatric population. Surgery on the growing spine, however, invokes concern regarding the potential for subsequent growth abnormalities, which is compounded by any disturbance related to the initial trauma. This article provides a review of the unique aspects of pediatric spinal anatomy, SCI mechanism patterns, and treatment options available for pediatric spine injuries along with their documented long-term outcomes.

Ultrasonography of the internal jugular vein in patients with dyspnea without jugular venous distention on physical examination

Study objective Accurate physical examination of patients with dyspnea is important. Jugular venous distention, however, can be difficult to assess in patients. The purpose of this case series is to serve as a pilot study of how ultrasonographic examination of the internal jugular vein compares with other measures of dyspnea. Methods This was a case series of 8 patients presenting with dyspnea without jugular venous distention on physical examination. Each patient underwent ultrasonographic examination of the internal jugular vein and inferior vena cava by an emergency physician sonographer blinded to all other clinical information after initial evaluation by another emergency physician for dyspnea. Results of ultrasonographic examination of the internal jugular vein and inferior vena cava were subsequently compared with initial emergency physician physical examination findings, initial chest radiography interpreted by radiologists, initial B-type natriuretic peptide levels, and final hospital discharge diagnosis. Results Ultrasonographic examination of the internal jugular vein compared more favorably with B-type natriuretic peptide levels and chest radiographic findings than ultrasonographic examination of the inferior vena cava in these patients with dyspnea but not jugular venous distention on physical examination. It was able to identify every patient diagnosed with cardiogenic pulmonary edema on hospital discharge. Conclusion Ultrasonographic examination of the internal jugular vein appears to be helpful in patients who present with dyspnea but do not have evidence of jugular venous distention on physical examination.

Clinical considerations in the diagnosis of otitis media.

Acute otitis media and otitis media with effusion are commonly encountered by both general practitioners and specialists. The diagnosis of otitis media requires a focused history and accurate physical examination. Unfortunately, many practitioners are either unaware of the criteria needed to make the diagnosis, or they incorrectly perform or misinterpret the physical examination. We review the pertinent historical and physical examination findings needed to accurately diagnose otitis media. Additionally, we examine the accessory tests that might help make the correct diagnosis in difficult cases. Finally, we address the issues involved in ensuring that both current and future physicians are appropriately trained in the diagnosis of this common illness.