JAMA Rational Clinical Exam

Question 1

JAMA - Does this patient have an Abnormal Systolic Murmur

Answer 1

\+LR: 
Late peaking murmur
Effort syncope
Mid-peaking murmur
Slow carotid upstroke
Brachioradial Delay

-LR: 
No murmur
No brachioradial delay
No apical carotid delay 
No radiation to carotid
Early peaking

Question 2

JAMA - Does this patient have Moderate-Severe AI

Answer 2

\+LR:
Diastolic BP <50
Leg-arm difference >20mmHg (Hill's test)
Pulse pressure >80
Louder murmur (indicates higher severity)
S3

-LR:
dBP >70
Leg-arm difference <40mmHg

Question 3

JAMA - Does this patient have ascites

Answer 3

+LR:
+ Fluid wave
+ Hx increasing abdominal girth

-LR:
No peripheral edema
No bulging flanks
No flank dullness

Question 4

JAMA - Does this patient have OSA

Answer 4

+LR:
Nocturnal choking/gasping
Morning H/A

-LR:
Mild snoring and BMI <26

Question 5

JAMA - Does this patient have CHF

Answer 5

\+LR:
Pulmonary edema on CXR
S3
Hx CHF
PND

-LR:
BNP <100 (NT-BNP <300)
No hx CHF
Normal CXR
No extertional SOB

Question 6

JAMA - does this patient with liver disease have cirrhosis

Answer 6

+LR:
-Ascites > Plt <160 > Spider Nevi

Others: Hx DM, Terry’s Nails, Gynecomastia, decreased body hair, ascites, spider nevi

-LR:
Plts >160
No hepatomegaly

Question 7

JAMA - Does this diabetic patient have osteomyelitis?

Answer 7

\+LR:
ESR >70
Bone visible
Ulcer area >2x2cm
Probe to bone
Abn Xray

• LR:
  Normal MRI

Question 8

JAMA - Does this patient have GCA?

Answer 8

\+LR:
Beaded temporal artery
Prominent temporal artery
Jaw claudication
Diplopia
Absent temporal artery pulse

-LR:
ESR <50
No H/A

Question 9

JAMA - Does this patient have a chronic wound infection?

Answer 9

+LR:
Increased pain
Positive swab

Question 10

JAMA - Does this female patient have osteoporosis?

Answer 10

\+LR: 
Wt <51kg, BMI<25
Occiput to wall distance >0cm
Tooth count <20
Rib:pelvis >2cm
Ht loss

-LR:
Weight >60

Question 11

JAMA - Will my patient fall?

Answer 11

\+LR:
Benzo/antidepressants
Dementia
Fall in the last month/year
Gait abnormality on exam

-LR:
No lower extremity disability
No OA

Question 12

JAMA - Does this patient have malaria?

Answer 12

\+LR:
Hyperbilirubinemia
Splenomegaly
Low plts
Fever
Jaundice

-LR:
No fever
Normal platelets
No headache

Question 13

JAMA - Does this patient have Parkinson’s Disease?

Answer 13

+LR:
Trouble turning in bed
Trouble opening jar
Bradykinesia + rigidity on exam

• LR:
  Lack of bradykinesia and rigidity
  Glabellar tap

Question 14

JAMA - Is this patient hypovolemic (due to blood loss)

Answer 14

+LR:
Postural dizziness/HR increase >30
Dry axilla (in elderly)

-LR:
Moist mucous membranes
Tongue without furrows

Question 15

JAMA - Does this patient have a thoracic aortic dissection?

Answer 15

+LR:
Focal neuro deficits
Pulse deficit
Hx tearing/ripping CP

-LR:
Normal mediastinum/aorta on XXR
No CP
Normal BP

Question 16

JAMA.- Does this patient have septic arthritis?

Answer 16

\+LR:
Syn fluid WBC >100000
Cellulitis w/ prosthesis
WBC >50000
Recent joint surgery

-LR:
SYnovial WBC<25k or <90% 
Normal ESR
Normal WBC
Able to move the joint without pain

Question 17

JAMA - Does this patient have LE PAD?

Answer 17

\+LR:
Claudication + Abn pulse
Cold leg
Any wound
Bruit
(Severe) - palpable pulse abn

-LR:
No claudication and no abn pulse
No bruit
No pulse abn

Question 18

JAMA - Does this patient have cardiac tamponade?

Answer 18

+LR:
Pulsus >12
Pulsus >10

-LR:
Pulsus <10
No cardiomegaly on CXR
No tachycardia, normal JVP

Question 19

JAMA - Does this patient have acute meningitis?

Answer 19

+LR:
Jolt accentuation

-LR:
Absence of fever AND neck stiffness AND altered LOC
Negative jolt

Question 20

JAMA - Does this patient with palpitations have a cardiac arrhythmia

Answer 20

ANY Arrhythmia:
+ LR: Palpitations while asleep/work or known cardiac dz
- LR: Duration history of panic disorder, <5 minutes

SIGNIFICANT Arrhythmia:

• • LR: regular rapid-pounding sensation in the neck, visible neck pulsations, palpitations while asleep
• -LR: regular palpitations (no pounding sensation)