Bedside Clinical Examination Research Articles

Comparison of Peyton's Four-Step Approach With the Conventional Bedside Technique in Teaching Clinical Examination Skills to Medical Students.

Conventional bedside teaching (CBT) is an integral and classical method for imparting clinical skills to undergraduates in medical schools. It is a traditionally successful approach, especially when it comes to imparting patient-doctor relationship skills and knowledge on clinical management.Peyton's four-step approach (PFSA) is one of the newer structured instructional approaches for teaching-learning, especially for imparting procedural and complex psychomotor skills.The present study compares the application of PFSA in teaching complex systemic examination skills to the CBT technique in teaching the same skill to MBBS students. The impact of the acquisition of this examination skill was assessed statistically to compare PFSA and CBT methodologies. The target population was MBBS (Bachelor of Medicine and Bachelor of Surgery)students; for this study, the phase II MBBS students were considered as the study population since they were relatively naïve to clinical bedside examination skills. Students were allotted groups and they were taught clinical skills through CBT and PFSA separately. Using the OpenEpi toolkit Version 3 open-source sample size calculator for comparing two means, the sample size was 30 students in each group. The students were assessed for their competency and were also made to fill out a feedback questionnaire to compare the two methods of education dispensing. Results: The results of this study showed that PFSA is definitely suitable for teaching clinical examination skills. The acquisition of skills was found non-inferior to CBT while the retention of these skills was found to be equally good or even superior with PFSA than with CBT. Conclusion:PFSA has already been proven to be a good teaching method for the acquisition of complex procedural skills. This study expands the role of PFSA in teaching clinical bedside examination skills to medical students.Further large-scale studies may clarify the learning impact and outcomes of PFSA in clinical bedside teaching.

Seeing through the myths: Practical aspects of diagnostic point-of-care ultrasound in nephrology.

Point of care ultrasonography (POCUS) is emerging as an invaluable tool for guiding patient care at the bedside, providing real-time diagnostic information to clinicians. Today, POCUS is recognized as the fifth pillar of bedside clinical examination, alongside inspection, palpation, percussion, and auscultation. In spite of growing interest, the adoption of diagnostic POCUS in nephrology remains limited, and comprehensive training beyond kidney ultrasound is offered in only a few fellowship programs. Moreover, several misconceptions and barriers surround the integration of POCUS into day-to-day nephrology practice. These include myths about its scope, utility, impact on patient outcomes and legal implications. In this minireview, we address some of these issues to encourage wider and proper utilization of POCUS.

Increased risk of persistent neuropathic pain after traumatic nerve injury and surgery for carriers of a human leukocyte antigen haplotype.

It is not known why some patients develop persistent pain after nerve trauma while others do not. Among multiple risk factors for the development of persistent posttrauma and postsurgical pain, a neuropathic mechanism due to iatrogenic nerve lesion has been proposed as the major cause of these conditions. Because there is some evidence that the human leukocyte antigen (HLA) system plays a role in persistent postsurgical pain, this study aimed to identify the genetic risk factors, specifically among HLA loci, associated with chronic neuropathic pain after traumatic nerve injuries and surgery in the upper extremities. Blood samples were taken to investigate the contribution of HLA alleles (ie, HLA-A, HLA-B, HLA-DRB1, HLA-DQB1, and HLA-DPB1) in a group of patients with persistent neuropathic pain (n = 70) and a group of patients with neuropathy without pain (n = 61). All subjects had intraoperatively verified nerve damage in the upper extremity. They underwent bedside clinical neurological examination to identify the neuropathic pain component according to the present grading system of neuropathic pain. Statistical analyses on the allele and haplotype were conducted using the BIGDAWG package. We found that the HLA haplotype A*02:01-B*15:01-C*03:04-DRB1*04:01-DQB1*03:02 was associated with an increased risk of developing persistent neuropathic pain in the upper extremity (OR = 9.31 [95% CI 1.28-406.45], P < 0.05). No significant associations were found on an allele level when correcting for multiple testing. Further studies are needed to investigate whether this association is on a haplotypic level or if certain alleles may be causing the association.

Structured Manual Muscle Testing of the Lower Limbs

An accurate and reliable neurological examination is pivotal in diagnosing patients with neurological and neurosurgical conditions. Despite the advancement of neuroscientific knowledge and the ever-progressing technologies and modalities that are being adopted to help achieve the challenge of accurate diagnosis, the neurologic examination is still crucial in both ambulatory and emergency settings. It provides the physician a tool to recognise neurologic involvement in certain disease states, and thereby allow proper work-up and treatment for patients. A basic neurologic examination can be performed rapidly with practice. Manual muscle testing of the lower limbs was carried out in accordance with a bedside clinical examination involving a clinical personnel examiner and a patient. This testing was performed in a rostro-caudal manner, starting from the hip and progressing to the toes. The neurological exam can be intimidating to perform for a lot of physicians. Deficiencies in accurate muscle testing have always presented a challenge for medical students and clinicians. By referring to the examination methods mentioned in our text and with the help of related video, it is our aim to improve the quality of neurological examination among medical personnel so that diseases may be recognised and managed earlier in their course.

Clinical examination of spatial neglect and other disorders of spatial cognition

Neglect occurring after stroke, neoplasms or degenerative processes can lead to considerable disability in everyday life as can other disorders of spatial orientation. Therefore, adedicated examination and early diagnostic classification are obligatory. Behavioral tests are helpful in this respect, enabling the clinician to obtain an initial overview of the existing deficits even at the patient's bedside. The clinical (bedside) examination of spatial neglect as well as the corresponding differential diagnostic procedure for the clarification of (possibly additionally or exclusively existing) hemianopia and extinction, as well as the examination of disorders of visuospatial perception, visuoconstructive disorders, topographic disorders, Bálint's syndrome, simultanagnosia, and optic ataxia are presented. The presentation is based on the newly revised (year 2023) guidelines of the Association of the Scientific Medical Societies in Germany (AWMF) on this subject area.

Similarities and Differences between Vestibular Migraine and Recurrent Vestibular Symptoms-Not Otherwise Specified (RVS-NOS).

Menière's disease and vestibular migraine (VM) are two common inner ear disorders whose diagnoses are based on clinical history and audiometric exams. In some cases, patients have been reporting different episodes of vertigo for years but not fulfilling the Bárány Society criteria for either. These are called Recurrent Vestibular Symptoms-Not Otherwise Specified (RVS-NOS). It is still under debate if this is a single disease entity or a part of the spectrum of already established disorders. The purpose of our work was to establish similarities and differences with VM in terms of clinical history, bedside examination, and family history. We enrolled 28 patients with RVS-NOS who were followed for at least 3 years with stable diagnosis; results were compared with those of 34 subjects having a diagnosis of definite VM. The age of onset of vertigo was lower in VM than in RVS-NOS (31.2 vs. 38.4 years). As for the duration of attacks and symptoms, we detected no differences other than subjects with RVS-NOS reporting milder attacks. Cochlear accompanying symptoms were more frequently reported by VM subjects (one subject reporting tinnitus and another one reported tinnitus and fullness). Motion sickness was equally reported by subjects across two samples (around 50% for both). Bipositional long-lasting, non-paroxysmal nystagmus was the most common finding in the two groups, with no significant difference. Finally, the percentage of familial cases of migrainous headache and episodic vertigo did not differ between the two samples. In conclusion, RVS-NOS shares some common aspects with VM, including the temporal profile of attacks, motion sickness (commonly considered a migraine precursor), bedside examination, and family history. Our results are not inconsistent with the possibility that RVS-NOS may be a heterogeneous disorder, even if some of these subjects may share common pathophysiological mechanisms with VM.

Manual Muscle Testing of the Scapula and the Upper Limb through Bedside Examination.

Neurological examination is an important tool in diagnosing patients with neurological and neurosurgical conditions. As the complexity and knowledge of neurological and neurosurgical conditions increases, we are now required to learn and indoctrinate our peers and students with the correct skills and methods of examination. Emphasis on the correct techniques of testing muscle strength is essential to avoid errors in recording muscle power and in testing specific muscles which may have overlapping functions. The manual muscle testing of muscles of scapula and upper limbs was performed as to mimic a bedside clinical examination and involved an examiner, a patient and a videographer. The manual muscle testing has been performed in rostrocaudal manner starting from the scapula and ending with the thumbs. A reliable and consistent method of manual muscle testing is lacking among students and clinicians. By adhering to the methods delineated in our text and accompanying video, we hope to reduce inter-examiner variability and increase the reliability and validity of this important examination.

Transcortical sensory aphasia heralding SARS-Cov-2-induced autoimmune encephalitis with gyral restricted diffusion hyperintensities: a novel case report

BackgroundCoronavirus disease 2019 (CoVID-19), primarily thought of as a respiratory system disease is actually a multi-system disease with immunological implications. CNS involvement in COVID has been explained in recent literature mainly for stroke, encephalopathy, encephalitis, acute disseminated encephalomyelitis and myelopathy. There are few studies characterizing clinical spectrum of COVID autoimmune encephalitis. We present a unique case of post-COVID autoimmune encephalitis in a diabetic male presenting with language dysfunction and novel radiologic findings.Case presentationPatient admitted to inpatient department of a tertiary care hospital of India was evaluated by bedside clinical examination, routine blood tests, CSF study with intrathecal SARS-Cov-2 antibody detection, commercially available tests for autoimmune encephalitis, neuroviral panel with HSV PCR, EEG, 3-Tesla MRI and PET scan. Patient was found to have personality change and transcortical sensory aphasia in the outset of COVID encephalitis. MRI findings like temporal involvement and insular ribboning are also being reported. The patient was treated with IV immunoglobulin and is on an improving course.ConclusionsThis case reports dysphasia due to COVID-mediated injury to the language networks, with novel radiologic findings. Role of parainfectious versus immune etiology is also discussed. Further studies are needed to elucidate the mechanism and clinical spectrum of post-COVID autoimmune encephalitis.

388. Does This Patient Have C. difficile Infection? A Systematic Review and Meta-Analysis

Abstract Background The clinical features of Clostridioides difficile infection overlap with many conditions. Accurate and early diagnosis of C. difficile is essential for reducing morbidity and mortality. We performed a systematic review to evaluate the diagnostic utility of clinical findings associated with C. difficile. Methods We included all studies that reported clinical features of C. difficile, a valid reference standard test for confirming diagnosis of C. difficile, and a comparison among patients with a positive and negative test result. The MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched up to September 2021. Meta-analyses using univariate and bivariate methods were used to determine estimates of sensitivity, specificity, and likelihood ratios (LRs). Results A total of 11,231 articles were screened and 46 were included for final analysis, enabling evaluation of 67 features for their diagnostic utility for C. difficile (10 clinical examination findings, 4 laboratory tests, 10 radiographic findings, prior exposure to 14 antibiotic types, and 29 clinical risk factors). Of the ten features identified on clinical examination, none were associated with increased likelihood of C. difficile infection. Features that increased likelihood of C. difficileinfection were stool leukocytes (LR 5.31, 95% CI 3.29-8.56), hospital admission in prior three months (LR 2.39, 95% CI 1.68-3.30), leukocytosis (LR 1.50, 95% CI 1.24-1.75), and low serum albumin (LR 1.43, 95% CI 1.06-1.97). Some clinical co-morbidities increased likelihood of C. difficile including congestive heart failure (LR 3.01, 95% CI 2.26-3.80) and end-stage renal disease (LR 3.85, 95% CI 1.73-7.57). Several radiographic findings also strongly increased the likelihood of C. difficile infection like pericolonic stranding (LR 10.72, 95% CI 9.59-11.84) and ascites (LR 2.91, 95% CI 1.76-4.80). Conclusion There is limited utility of bedside clinical examination alone in detecting or ruling out C. difficile infection. Accurate diagnosis of C. difficile infection requires a combination of thoughtful clinical assessment and interpretation of test results. However, microbiologic testing is needed for confirmation in all suspected cases. Disclosures All Authors: No reported disclosures.

NEW TECHNOLOGIES IN DENTISTRY: THE USE OF LOW POWER LASER TO TREAT ACUTE HERPETIC GINGIVOSTOMATITIS

A 10-year-old pediatric patient diagnosed with cystic fibrosis was hospitalized due to an important clinical picture of acute primary herpetic gingivostomatitis (GEHA), with severe painful symptoms and difficulty in feeding orally. At the bedside evaluation and clinical examination, multiple ulcerated lesions were observed on the upper and lower lip, gingival ridge, and lingual dorsum, associated with pseudomembranous candidiasis on the tongue. We opted for the application of low-power laser daily, diet and hygiene guidance, and prescription of antiviral and antifungal drugs. Patient showed significant improvement on the third day of photobiomodulation associated with other care, with reintroduction of oral feeding and decreased use of analgesic therapy. Thus, understanding the complexity of viral infections associated with immunosuppression is important for making the correct diagnosis. The access to new technologies in dentistry improved the clinical condition of GEHA and the quality of life of the patient.

Simultaneous idiopathic benign paroxysmal positional vertigo and labyrinthitis on different side of ear: A rare occasion of acute vestibulopathy lead to delay in management

Dizziness and acute vertigo are common presenting complaints in the Emergency Department or primary care setting. The etiology can be broadly divided into peripheral and central vestibular disorders and need to be differentiated expeditiously as management is completely different. Diagnosis of unilateral peripheral vestibular disorder (PVD) is usually straight forward based on clinical bed side examination finding. Diagnosis becomes more challenging when a patient presents with bilateral PVD or concomitant pathologies that can lead to delay in diagnosis and management. We report a case of rare simultaneous idiopathic benign paroxysmal positional vertigo (BPPV) and labyrinthitis occurring on different side of the ear.International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 Page: 222-226

International survey of neuromonitoring and neurodevelopmental outcome in children and adults supported on extracorporeal membrane oxygenation in Europe.

Adverse neurological events during extracorporeal membrane oxygenation (ECMO) are common and may be associated with devastating consequences. Close monitoring, early identification and prompt intervention can mitigate early and late neurological morbidity. Neuromonitoring and neurocognitive/neurodevelopmental follow-up are critically important to optimize outcomes in both adults and children. To assess current practice of neuromonitoring during ECMO and neurocognitive/neurodevelopmental follow-up after ECMO across Europe and to inform the development of neuromonitoring and follow-up guidelines. The EuroELSO Neurological Monitoring and Outcome Working Group conducted an electronic, web-based, multi-institutional, multinational survey in Europe. Of the 211 European ECMO centres (including non-ELSO centres) identified and approached in 23 countries, 133 (63%) responded. Of these, 43% reported routine neuromonitoring during ECMO for all patients, 35% indicated selective use, and 22% practiced bedside clinical examination alone. The reported neuromonitoring modalities were NIRS (n = 88, 66.2%), electroencephalography (n = 52, 39.1%), transcranial Doppler (n = 38, 28.5%) and brain injury biomarkers (n = 33, 24.8%). Paediatric centres (67%) reported using cranial ultrasound, though the frequency of monitoring varied widely. Before hospital discharge following ECMO, 50 (37.6%) reported routine neurological assessment and 22 (16.5%) routinely performed neuroimaging with more paediatric centres offering neurological assessment (65%) as compared to adult centres (20%). Only 15 (11.2%) had a structured longitudinal follow-up pathway (defined followup at regular intervals), while 99 (74.4%) had no follow-up programme. The majority (n = 96, 72.2%) agreed that there should be a longitudinal structured follow-up for ECMO survivors. This survey demonstrated significant variability in the use of different neuromonitoring modalities during and after ECMO. The perceived importance of neuromonitoring and follow-up was noted to be very high with agreement for a longitudinal structured follow-up programme, particularly in paediatric patients. Scientific society endorsed guidelines and minimum standards should be developed to inform local protocols.

Republication de : The Bedside Clinical Examination as a key element of the swallowing assessment during the COVID 19 Pandemic

Annales Francaises d'Oto-Rhino-Laryngologie et de pathologie cervico-faciale - Vol. 138 - N° 4 - p. 321-322

The assessment of cognitive and behavioural disturbances in vascular cognitive impairment (VCI) - recommendations of an expert working group.

With newer research-based classification systems, the term Vascular Cognitive Impairment (VCI) is now preferred to vascular dementia. VCI is an umbrella term that includes all forms of cognitive deficits ranging from mild cognitive impairment of vascular origin (VaMCI) to vascular dementia (VaD). The new VCI construct takes into account the fact that in addition to single strategic infarcts, multiple infarcts, and leukoaraiosis, there are other mechanisms of cerebrovascular disease such as chronic hypoperfusion that might account for the pattern of cognitive deficits associated with vascular dementia. The key to defining the spectrum of VCI is neuropsychological testing, bedside or office-based clinical examination, and neuroimaging. The lack of specific cognitive tools that are sufficiently sensitive to detect subtle deficits makes the assessment of cognitive impairment difficult. Prospective cross-sectional and longitudinal studies of VCI from different settings are therefore required. Although there have been few published reports, behavioural and psychological symptoms (BPS) are inherently present in VCI from the onset and during the course of the disease. Besides the type of population (i.e. clinical, community or nursing-home settings), the definition of VCI/VaD and the instruments used, and differences in the prevalence and pattern of BPS between various studies, could be due to other, often unconsidered, factors such as gender, age, education, use of medication and VCI/VaD severity.

How-to: Focus Cardiac Ultrasound in acute settings.

Focus cardiac ultrasound (FoCUS) provides vital information at at the bedside which has the potential of improving outcomes in the acute settings. FoCUS could help the clinicians in their daily clinical decision-making while applied within the clinical context as an extension of bedside clinical examination. FoCUS practitioners should be aware of their own limitations with the importance of the timely referral for comprehensive Echocardiography whenever required.

Significant differences in written assessments as a result of a blended learning approach used in a clinical examination course in internal medicine: a randomized controlled pilot study.

Background: Taking a medical history and performing a physical examination represent basic medical skills. However, numerous national and international studies show that medical students and physicians-to-be demonstrate substantial deficiencies in the proper examination of individual organ systems.Aim: The objective of this study was to conduct a randomized controlled pilot study to see if, in the context of a bedside clinical examination course in internal medicine, an additional app-based blended-learning strategy resulted in (a) higher satisfaction, better self-assessments by students when rating their history-taking skills (b1) and their ability to perform physical examinations (b2), as well as (c) higher multiple-choice test scores at the end of the course, when compared to a traditional teaching strategy.Methods: Within the scope of a bedside course teaching the techniques of clinical examination, 26 students out of a total of 335 students enrolled in the 2012 summer semester and 2012/2013 winter semester were randomly assigned to two groups of the same size. Thirteen students were in an intervention group (IG) with pre- and post-material for studying via an app-based blended-learning tool, and another 13 students were in a control group (CG) with the usual pre- and post-material (handouts). The IG was given an app specifically created for the history-taking and physical exam course, an application program for smartphones enabling them to view course material directly on the smartphone. The CG received the same information in the form of paper-based notes. Prior to course begin, all of the students filled out a questionnaire on sociodemographic data and took a multiple-choice pretest with questions on anamnesis and physical examination. After completing the course, the students again took a multiple-choice test with questions on anamnesis and physical examination.Results: When compared to the CG, the IG showed significantly more improvement on the multiple-choice tests after taking the clinical examination course (p=0.022). This improvement on the MC tests in the IG significantly correlated with the amount of time spent using the app (Spearman’s rho=0.741, p=0.004).Conclusion: When compared to conventional teaching, an app-based blended-learning approach leads to improvement in test scores, possibly as a result of more intensive preparation for and review of the clinical examination course material.

Eponymous signs in toxicology and poisoning in the nineteenth and early twentieth centuries.

Toxicology emerged as an independent discipline in the early nineteenth century and has been aided by the development of numerous sophisticated tests that allow physicians and scientists to identify, quantify, and quantitate elements, chemicals, compounds, and toxins and to sort them into their component parts. These developments also contributed to enrich toxicological terminology with many new terms and eponyms in particular. Eponyms are ascribed to a variety of phenomena including attributing, in many cases, to the person who first identified or described a particular phenomenon and are named for the variety of findings found during the medical, surgical, pathological, or laboratory evaluation. Focusing on eponymous signs caused by poisons and toxins, the purpose of this paper is to honor the eponymous persons who first discovered, described, or more fully elaborated the finding. Nearly 30 associated eponyms have been identified in the literature, half of which were named for persons (e.g., Anstie sign, Billard sign, Blyth sign, Burton sign/line, Corrigan sign, Hertoghe sign, Peary sign). We believe that they are important to learn as they impart an in-depth appreciation of their role and application during the clinical examination. Knowledge of the person's biographical accomplishment(s) and character imparts a personalized and humane qualities to these signs from a medico-historical perspective. Understanding these signs and how to recognize them provides a method applying the bedside clinical examination to further support clinical suspicion or diagnose disease.

Imaging and Clinical Data on Swallowing Function of Individuals with Huntington's Disease and Dysphagia.

Dysphagia is common in Huntington's disease (HD) affecting all phases of swallowing. Correlations exist between non-instrumental measures of dysphagia and clinical features of HD, including age, disease duration and degree of motor impairment. Lack of instrumental data limits our ability to wholly characterize HD-related dysphagia and prognosticate swallowing changes over time. To retrospectively describe a relatively large database of videofluoroscopic studies (VFSSs) and determine the relationships between dysphagia and HD clinical parameters, including disease duration and burden of pathology score. Medical and swallowing data of 49 individuals with HD and dysphagia were examined. VFSS data were interpreted using the Bethlehem Assessment Scale and Penetration-Aspiration Scale. Data from clinical bedside examination and social information were collated to describe the impact of dysphagia in HD. Repeated VFSS data were available for seven individuals. Swallowing was characterized by lingual dysfunction, reduced soft palate elevation, delayed pharyngeal swallow initiation, and inability to clear matter from the pharynx. Two-thirds of cases presented with compromised airway protection with both liquid and solid consistencies. Tachyphagia and difficulty self-feeding were common. Dysphagia correlated with disease severity and duration. Longitudinal analysis revealed a mixed pattern of progression with some individuals presenting with worsening dysphagia whilst others appeared to remain stable or improved in function. Dysphagia in HD is exacerbated by difficulties with self-feeding and monitoring feeding rate. Burden of pathology relates to pharyngeal swallow initiation and penetration and aspiration of fluid. Dysphagia did not appear to worsen in a systematic way in a subset of participants.

Fluid administration for acute circulatory dysfunction using basic monitoring.

This review aims at evaluating the role and the effectiveness of basic hemodynamic monitoring to guide and to titrate fluid administration during acute circulatory dysfunction. Fluid infusion is a cornerstone of the management of acute circulatory dysfunction. This is a time-related situation, which should be promptly faced to avoid multi organ dysfunction. For this purpose, the recognition of clinical signs of acute circulatory dysfunction is of pivotal importance. A prompt fluid resuscitation in the early phase of acute circulatory failure is a key and recommended intervention, on the other hand the hemodynamic targets and the safety limits indicating whether or not stopping this treatment in already resuscitated patients are still undefined. Bedside clinical examination has been demonstrated to be a reliable instrument to recognize the mismatch between cardiac function and peripheral oxygen demand. Mottling skin and capillary refill time have been recently proposed using a semi-quantitative approach as reliable tool to guide shock therapy; lactate level, central venous oxygen saturation and venous-to-arterial CO2 tension difference are also useful to track the effect of the therapies overtime. Finally, the availability of echocardiography miniaturization of the machines has boosted this technique as part of the daily clinical assessment of patient, inside and outside the intensive care units (ICUs).

Sensitivity and specificity of cerebrospinal fluid glucose measurement by an amperometric glucometer.

Objectives:To provide more data regarding the role of an amperometric glucometer in diagnosing meningitis.Methods:This is a prospective study conducted at the Pediatric and Neonatology Department, Qatif Central Hospital, Qatif, Saudi Arabia between March 2017 and September 2018. We measured glucose concentrations in cerebrospinal fluid (CSF) and blood using a central laboratory and amperometric glucometer (AG). We compared CSF/blood glucose ratios obtained in a central laboratory from clinical bedside examination with a glucometer, and calculated the sensitivity and specificity for detecting cases of meningitis.Results:A total of 101 patients with clinical suspicion of meningitis were recruited for CSF sampling. Of 101 CSF samples, 61 (60%) were suggestive of meningitis. Of 101 samples, 47 had hypoglycorrhachia identified by a standard laboratory, and 17% of them were also detected by AG. The correlation between CSF/blood glucose by AG and laboratory ratios was substantial (r=0.894, p<0.01, 95% CI: 0.805-0.983). The AG sensitivity was 100% and specificity was 55% in pediatric cases, while in neonates the sensitivity was 86% and the specificity was 26%.Conclusion:Amperometric glucometers can be used to detect hypoglycorrhachia accurately. This point-of-care testing tool is easily accessible and can be used by health care providers for cases suspected of meningitis.