PhysicalDiagnosis Flashcards
A postural dizziness (severe enough to stop the test) or an increase in heart rate of at least _ beats/minute has sensitivity of 97% and specificity of 96% for blood loss >630 mL.
Unless associated with _, postural hypotension of any degree has little value.
A postural dizziness (severe enough to stop the test) or an increase in heart rate of at least 30 beats/minute has sensitivity of 97% and specificity of 96% for blood loss >630 mL.
Unless associated with dizziness, postural hypotension of any degree has little value.
Body fat “distributions” by waist circumference (WC) and waist-to-hip ratio(WHR) are much better markers for cardiovascular risk than the body mass index (BMI) alone.
In fact, a WC <100 cm practically _ _ _.
Body fat “distributions” by waist circumference (WC) and waist-to-hip ratio(WHR) are much better markers for cardiovascular risk than the body mass index (BMI) alone.
In fact, a WC <100 cm practically excludes insulin resistance.
An acute difference in systolic pressure > _ mmHg between the two arms usually indicates _ _ (complicated by aortic regurgitation in cases of more proximal dissection).
If chronic, it indicates instead a subclavian artery _ or a subclavian _ syndrome.
An acute difference in systolic pressure >20 mmHg between the two arms usually indicates aortic dissection (complicated by aortic regurgitation in cases of more proximal dissection).
If chronic, it indicates instead a subclavian artery occlusion or a subclavian steal syndrome.
An ankle-to-arm systolic pressure index (AAI) < _ identifies patients with angiographically proven occlusions/stenoses of lower extremities arteries with 96% sensitivity and 94–100% specificity.
Most patients with claudication will have AAI values between _ and _, whereas those with pain at rest will have values < _. Indexes <0.2 are associated with ischemic or gangrenous extremities.
An ankle-to-arm systolic pressure index (AAI) <0.97 identifies patients with angiographically proven occlusions/stenoses of lower extremities arteries with 96% sensitivity and 94–100% specificity.
Most patients with claudication will have AAI values between 0.5 and 0.8, whereas those with pain at rest will have values <0.5. Indexes < 0.2 are associated with ischemic or gangrenous extremities.
Significance
chronic hypoalbuminemia
Paired, transverse, white nail bands in the second, third, and fourth fingers (Muehrcke’s lines) suggest chronic hypoalbuminemia, occurring in more than three quarters of patients with:
- nephrotic syndrome (<2.3 gm/100 mL)
- liver disease
- malnutrition.
Acrochordons: significance
IGT or type 2 DM
In a study of 118 subjects with acrochordons (skin tags), 41% had either impaired glucose tolerance or overt type 2 diabetes.
Vitiligo: Trigger
10% have serologic or clinical evidence of autoimmune disorders;
- hypothyroidism of the Hashimoto variety.
- Diabetes,
- Addison’s,
- pernicious anemia,
- alopecia areata, and
- uveitis (Vogt-Koyanagi syndrome) also are frequent.
Acanthosis nigricans: DxTrigger
20%: aggressive neoplasm
Of these, (GI) adenocarcinoma: 90% , Gastric cancer: 60%.
Most: obesity and insulin resistance.
Jaundice in dark skinned patients
- Ask the patient to look upward.
- Inspect the inferior conjunctival recess.
- Should be white in nonicteric subjects, since the brownish discoloration of these individuals is the result of sunlight exposure.
Nonproliferative diabetic retinopathy: earliest signs
Earliest signs of nonproliferative diabetic retinopathy include microaneurysms and dot intraretinal hemorrhages, with progression of disease characterized by an increase in number and size of microaneurysms and intraretinal hemorrhages (both dot and blot).
Soft exudates are not as predictive, and hard exudates even less.
Diagonal earlobe crease
Diagonal earlobe creases in adults are an acquired phenomenon and a significant independent variable for coronary artery disease. Hair in the external ear canal also seems to be associated with coronary artery disease.
Centcor criteria
XFELA
(1) pharyngeal or tonsillar exudates,
(2) fever,
(3) tonsillar enlargement,
(4) anterior cervical and jugulodigastric lymph adenopathy
(5) absence of cough.
Multiple white, warty, corrugated, and painless plaques on the lateral margins of the tongue
Multiple white, warty, corrugated, and painless plaques on the lateral margins of the tongue (hairy leukoplakia) represent an Epstein-Barr–induced lesion typical of HIV infection, even though this can also occur in severely immunocompromised organ transplant patients. If present, it carries a worse prognosis for HIV progression.
Reversible SVC obstruction by raising arm
Pemberton’s maneuver (reversible superior vena cava obstruction caused by a substernal goiter being “lifted” into the thoracic inlet as a result of arm raising) is a nonspecific finding that may be encountered in patients with substernal thyroid masses, lymphomas, or upper mediastinal tumors.
Thyroid nodule size: detectability
The average size of a thyroid nodule detected on exam is 3 cm. In fact, the larger the nodule, the more likely its detection (with <1 cm nodules being missed 90% of the time; <2 cm nodules 50% of the time)
Hyperthyroidism: useful signs
- lid retraction (likelihood ratio [LR] = 31.5),
- lid lag (LR = 17.6),
- fine finger tremor (LR = 11.4),
- warm skin (LR = 6.7),
- tachycardia (LR = 4.4).
Findings more likely to rule out hyperthyroidism:
- normal thyroid size (LR = 0.1),
- heart rate <90/minute (LR = 0.2)
- no finger tremor (LR = 0.3).
Older hyperthyroid patients exhibit more anorexia and atrial fibrillation; more frequent lack of goiter; and overall fewer signs, with tachycardia, fatigue, and weight loss in more than 50% of patients (and all three in 32%).
Hypothyroidism: signs
- Bradycardia (LR = 3.88),
- abnormal ankle reflex (LR = 3.41), and
- coarse skin (LR = 2.3).
No single finding, when absent, can effectively rule out hypothyroidism.
Utility of CBE
Clinical breast exam (CBE) has low sensitivity for the detection of breast masses, high specificity.
Accuracy that can be increased by (1) longer duration of exam (at least 3 minutes per breast); (2) higher number of correct steps (a systematic and vertical search pattern, thoroughness, varying palpation pressure, use of three fingers, finger pads, and circular motion); and (3) examiner experience (previous training with silicone models).
Arterial upstroke quality: significance
A brisk arterial upstroke + widened pulse pressure: aortic regurgitation (AR).
Brisk arterial upstroke + normal pulse pressure: indicates:
- MR
- VSD
- HOCM
either the simultaneous emptying of the left ventricle into a high pressure bed (the aorta) and a lower pressure bed (like the right ventricle in patients with ventricular septal defect, or the left atrium in patients with mitral regurgitation) or hypertrophic obstructive cardiomyopathy (HOCM).
Pulsus alternans: significance
severe LV dysfunction
The alternation of strong and weak arterial pulses despite regular rate and rhythm (pulsus alternans) indicates severe LV dysfunction, with worse ejection fraction and higher pulmonary capillary pressure. Hence, it is often associated with an S3 gallop.
Visible neck veins in the upright position: significance
CVP > 7
Visible neck veins in the upright position indicate a central venous pressure >7 cmH2O and thus are pathologic.
Significance of JVD and S3
In chronic heart failure, jugular venous distention represents an ominous prognostic variable, independently associated with adverse outcomes, including risk of death or hospitalization. The presence of S3 is similarly (and independently) associated with increased risk.
end-inspiratory crackles: sensitivity, specificity
Presence of either end-inspiratory crackles or distended neck veins has high specificity (90–100%) but low sensitivity (10–50%) for increased left-sided filling pressure due to either systolic or diastolic dysfunction
Abdominojugular reflux: sensitivity, specificity
Positive abdominojugular reflux has equally high specificity (but better sensitivity, 55–85%) for increased left-sided filling pressure.
S3 gallop, downward and lateral displacement of the apical impulse, and peripheral edema also have high specificity (>95%) but low sensitivity (10–40%).
Of these, only the S3 and the displaced apical impulse have a positive likelihood ratio (5.7 and 5.8, respectively).
JVP: which jugular vein?
Right
The right internal jugular venous pulse is generally preferred for assessing right heart hemodynamics since the right internal jugular vein is in a direct line with the superior vena cava. On the other hand, the external jugular veins are more easily assessed than the internal jugular veins and can provide accurate results. We suggest examination of the right external jugular vein when the right internal jugular vein cannot be adequately visualized.
The mean level of venous pressure normally declines during inspiration but the amplitude of the a wave increases. Lack of a decrease or an increase in jugular venous pressure during inspiration
Kussmaul sign
Numerous problems:
Constrictive or effusive pericarditis; other findings suggestive of chronic pericardial constriction include sharp y descent, diastolic left parasternal impulse, and pericardial knock. (See “Differentiating constrictive pericarditis and restrictive cardiomyopathy”.)
●Restrictive cardiomyopathy.
●Predominant right ventricular infarction; in patients with inferior or inferoposterior acute myocardial infarction, the presence of Kussmaul’s sign almost invariably indicates predominant right ventricular infarction [5,12,13].
●Severe right ventricular dysfunction
●Massive pulmonary embolism.
●Partial obstruction of the vena cavae.
●Right atrial and right ventricular tumors.
●Severe tricuspid regurgitation
●Occasionally tricuspid stenosis and congestive heart failure.
●Rarely cardiac tamponade.
Hepatojugular reflux: duration of compression, positive test criterion
10 to 15 second, JVD increase of > 3 cm
Raising the legs or abdominal compression increases venous return and pressure.
- applying firm, sustained pressure for 10 to 15 seconds over the upper abdomen while the patient is breathing quietly.
- Normal: maneuver transiently increases jugular pressure by only approximately 1 to 3 cm.
- In patients with right ventricular failure, however, sustained elevation of venous pressure usually greater than 3 cm is observed during continued compression (positive hepatojugular reflux).
Abdominojugular reflux: significance
In patients presenting with dyspnea, an abdominojugular reflux argues in favor of bi-ventricular failure and suggests a PCPW >15 mmHg.
Negative: argues strongly against increased left atrial pressure
PIC after MI
Ominous
Posturally induced crackles (PICs) after myocardial infarction (MI) carry an ominous sig-nificance, reflecting higher PCWP, lower pulmonary venous compliance, and higher mortality. After the number of diseased coronary vessels and the patient’s pulmonary capillary wedge pressure, PICs rank third as most important predictor of recovery after an acute MI.
S3 and IHD: significance
Ischemic heart disease patients with S3 have a 1-year mortality that is much higher than those without it (57% versus 14%).
The same applies to a displaced apical impulse (39% versus 12%).
Leg swelling without increased CVP: significance
- bilateral venous insufficiency
- noncardiac edema (hepatic or renal).
Manouver for detecting LV dysfunction
The Valsalva maneuver
has excellent specificity and sensitivity (90–99% and 70–95%, respectively) for detecting left ventricular dysfunction, either systolic or diastolic.
supine or semirecumbent position and instructed to exhale forcefully against a closed glottis). Signs of adequacy include neck vein distension, increased tone in the abdominal wall muscles, and a flushed face. Maintain the strain for 10 to 15 seconds and then release it and resume normal breathing.
A modified Valsalva maneuver, which involves the standard strain (40 mmHg pressure for 15 seconds in the semirecumbent position) followed by supine repositioning with 15 seconds of passive leg raise at a 45 degree angle, has been shown to be more successful in restoring sinus rhythm for patients with SVT
lthough seldom used in current practice, the Valsalva maneuver has been evaluated in patients with heart failure and/or left ventricular dysfunction. Patients who are performing the Valsalva maneuver for diagnostic purposes in this setting should have continuous blood pressure monitoring along with continuous heart rate monitoring (single-lead telemetry is adequate here) during the maneuver. When non-invasively monitoring blood pressure responses using a blood pressure cuff, the cuff should be inflated to approximately 15 mmHg above the patient’s resting systolic blood pressure, and the investigator should auscultate the brachial artery throughout the maneuver and for 15 to 30 seconds afterward.
Blood pressure responses following a Valsalva maneuver — The expected blood pressure response in normal subjects is divided into four phases (figure 1) [13]. Phases 1 and 2 occur during the active strain phase of the Valsalva maneuver, while phases 3 and 4 occur after the strain phase has been completed. The normal pattern of systolic blood pressure has been named the “sinusoidal” response.
●Phase 1 is characterized by a >15 mmHg rise in the patient’s systolic blood pressure that occurs at the onset of straining and typically lasts less than five seconds. Phase 1 occurs because of increased intrathoracic pressure.
●Phase 2 is typified by a return of the systolic blood pressure to baseline (below the 15 mmHg increase) during the remainder of the straining phase. Phase 2 occurs due to decreased venous return (leading to a decrease in stroke volume) and an increase in systemic vascular resistance. Relative tachycardia may occur during this phase [15].
●Phase 3 occurs after release of the strain and is distinguished by an abrupt fall in systolic blood pressure below baseline. Phase 3 occurs due to an acute decrease in intrathoracic pressure.
●Phase 4 follows and is identified by a secondary rise in systolic blood pressure >15 mmHg above baseline. Phase 4 occurs because of a reflex sympathetic response to the decrease in systolic blood pressure encountered during phase 3. Relative bradycardia may occur during this phase.
Whil
Low cardiac index: physical sign
The PPP (proportional pulse pressure—arterial pulse pressure divided by the systolic blood pressure) has excellent sensitivity (91%) and specificity (83%) for identifying low cardiac index (CI).
A PPP <0.25 has a positive likelihood ratio of 5.4 for CI of 2.2 L/min/m2.
CHF signs but clear lungs
Cardiac tamponade
Patients with distended neck veins, dyspnea/tachypnea, tachycardia, and clear lungs should be thought of as having tamponade; thus, their pulsus paradoxus must be measured
A pulsus paradoxus > _ mmHg has good sensitivity and excellent specificity for tamponade. It also may be palpable.
A pulsus paradoxus >21 mmHg has good sensitivity and excellent specificity for tamponade. It also may be palpable.
Constrictive pericarditis: physical sign but not of tamponade
A paradoxical increase in venous distention during inspiration (Kussmaul’s sign) is not a feature of tamponade but does occur in 30–50% of patients with “pure” constrictive pericarditis; 90% of patients with constrictive pericarditis also have a retracting apical impulse.
Loud S1: trigger
MS
A loud S1 should always alert the clinician to the possibility of mitral stenosis and should thus prompt a search for its associated diastolic rumble.
Physiologic splitting of S2 varies with:
Age
An audible physiologic splitting of S2 is age dependent, present in 60% of subjects younger than 30 and 30% of those older than 60.
Wide splitting of S2
Wide splitting of S2 usually reflects a delayed closure of the pulmonic valve because of either a right bundle branch block or pulmonary hypertension.
Fixed S2 split
ASD
S2 that remains audibly split throughout respiration, both in the supine and upright positions, with a consistent interval between its two components, argues in favor of an atrial septal defect.
S2: paradoxical splitting
S2 that becomes audibly split only in exhalation, while remaining single in inspiration (paradoxical or reversed splitting), means pathology until proven otherwise. This is usually an increased impedance to left ventricular emptying (aortic stenosis, coarctation, or hypertension), a left bundle branch block, or a transient, left ventricular ischemia.
Mechanism of physiologic S2 split
- Inspiration causes preferential filling of the right ventricle (increased venous return to RA, decreased venous return to LA)
- During inspiration, intrathoracic pressure decreases causes ncrease in venous return into right atrium.
- Inspiration causes decrease in LA return because lungs are exposed to a further increase in the magnitude of negative pressure.
- Simultaneously, there is a reduction in blood volume returning from the lungs into the left atrium (because of the vacuum surrounding the lungs, and PVR is lower because of lung expansion).
- Since there is an increase in blood volume in the right ventricle during inspiration, the pulmonary valve (P2 component of S2) stays open longer during ventricular systole whereas the aortic valve (A2 component of S2) closes slightly earlier due to a reduction in left ventricular volume.
- Thus the P2 component of S2 is delayed relative to that of the A2 component.
- Only heard in the pulmonic area
During expiration, the chest wall collapses and decreases the negative intrathoracic pressure (compared to inspiration). Therefore, there is no longer an increase in blood return to the right ventricle versus the left ventricle and the right ventricle volume is no longer increased. This allows the pulmonary valve to close earlier such that it overlaps the closing of the aortic valve, and the split is no longer heard.
Loud ringing S2
A loud and ringing S2, rich in overtones and tambour like (“drum” in French), indicates a dilation of the aortic root. When associated with an aortic regurgitation murmur, it suggests Marfan syndrome, syphilis (Potain’s sign), or a dissecting aneurysm of the ascending aorta (Harvey’s sign).
S3 absence
S3 is such an accurate predictor of systolic dysfunction (and elevated atrial pressure) that its absence argues in favor of an ejection fraction >30%.
S3 during pre-op eval
In patients with congestive heart failure, S3 is the best predictor for response to digitalis and overall mortality. It correlates with high levels of B-type natriuretic peptide (BNP), and if associated with elevated jugular venous pressure, it predicts more frequent hospitalizations and worse outcome. S3 is also the most significant predictor of cardiac risk during noncardiac surgery. If preoperative diuresis is not instituted, it can also predict mortality. Finally, the presence of S3 in mitral regurgitation reflects worse disease (i.e., higher filling pressure, lower ejection fraction, and more severe regurgitation).
S4 significance
S4 reflects an increase in late ventricular diastolic pressure (hence a diastolic dysfunction); but, in contrast to S3, it reflects normal atrial pressure, normal cardiac output, and normal ventricular diameter.
S4: sensitivity for MI
S4 can be heard in as many as 90% of patients with MI, but eventually resolves. Presence of S4 at more than 1 month after MI does predict a higher 5-year mortality rate.
Early systolic sound: signifies
An early systolic (ejection) sound indicates normal ejection of blood through an abnormal aortic valve (i.e., bicuspid), normal ejection of blood into a stiffened and dilated aortic root (i.e., hypertension, atherosclerosis, aortic aneurysm, or aortic regurgitation), or forceful ejection of blood into a normal aortic root (high output states like aortic regurgitation).
Aortic ES in patient with AR: signifies
An aortic ES in patients with aortic regurgitation (AR) argues in favor of valvular AR, possibly due to a bicuspid valve.
All right-sided auscultatory findings (except the pulmonic ejection sound) get louder on (Rivero Carvallo maneuver).
inspiration
murmur that intensifies with Valsalva or squatting-to-standing is due to either
HOCM or MVP
Benign functional murmur characteristics
systolic, short, soft (typically <3/6), early peaking
- (never passing midsystole),
- predominantly circumscribed to the base, and a
- well-preserved and normally S2.
- Otherwise normal cardiovascular exam ;
- Often disappears with sitting, standing, or following Valsalva.
“Bad” systolic murmur characteristics
- Long, loud
- late peaking,
- nonlocalized,
- soft-to-absent S2 that does not normally split.
- Abnormal findings/symptoms (“bad” company).
Aortic sclerosis murmur: significance
murmur of aortic sclerosis is the most common systolic ejection murmur of the elderly, affecting 21–26% of persons older than 65 and 55–75% of octogenarians and carrying a 40% increased risk of myocardial infarction.
Murmur of AS: significance of Ejection click
Presence of an early systolic (ejection) click in aortic stenosis (AS) usually indicates a valvular AS, typically due to a congenitally bicuspid aortic valve.
Some patients with AS may exhibit a dissociation of the systolic murmur into two components, with medium frequencies transmitted to the base and high frequencies to the apex, almost mimicking MR.
Gallavardin phenomenon
Aortic stenosis murmur
In favor:
- reduced/delayed carotid upstroke,
- mid-to-late peak of the murmur
- Soft-to-absent A2
- Precordial thrill
- Apical-carotid (or brachioradial) delay.
Against:
- Lack of radiation to the right carotid artery.
- Normal rate of rise of the arterial pulse argues also against the presence of significant AS, but only in the young.
S4 in AS: significance
severe left ventricular hypertrophy
(with a transvalvular pressure gradient >70 mmHg), but only in younger patients (older subjects may already have a “normal” S4).
Rheumatic MR vs MVP MR
Rheumatic: Plateau mitral regurgitation (MR) murmurs are more likely to be rheumatic,
MVP or papillary muscle dysfunction: start in midsystole and “grow” into S2
Valvular AR vs “root” AR
Valvular AR: loudest over the Erb’s point (left parasternal area)
“root” AR is loudest over the aortic area (right parasternal area).
S2 best auscultated at:
Erb’s point refers to the third intercostal space on the left sternal border where S2 heart sound is best auscultated.[4][5] Some sources in
Austin Flint murmur
An apical diastolic rumbling murmur in pure aortic regurgitation.
Several mechanisms have been proposed:
- fluttering of the mitral valve from the impingement by the aortic regurgitant jet,
- relative (functional) mitral stenosis
- regurgitant jets directed against the left ventricular free wall
Tachypnea sensitivity for PE
92%
Tachypnea is so frequent in pulmonary embolism (92% of patients) that a normal respiratory rate argues strongly against the diagnosis.
Platypnea: causes
Platypnea (an obligatory “supine respiration”) is usually due to a right-to-left shunt.
- intracardiac or
- intrapulmonary (common in cirrhosis from hepatopulmonary syndrome).
Crackles and rhonchii that clear with coughing
Crackles (and rhonchi) that clear with coughing suggest airflow obstruction.
Post-tussive crackles: signifies
Tuberculosis
Bronchial breath sounds: significance
Consolidation
Bronchial breath sounds reflect patent airways in a setting of absent alveolar air, with replacement by media that better transmit higher frequencies, such as liquids or solids (consolidation).
If unaccompanied by crackles: pleural effusion.
Inspiratory crackles: timing implications
- early: bronchitis
- mid-inspiratory crackles: bronchiectasis
- Late: interstitial fibrosis or edema.
Pneumonia: sequence of findings
- First: crackles and diminished sounds
- 1-3 days: bronchial breath sounds, egophony
- Later: dullness to percusion
crackles and diminished breath sounds appear first; bronchial breath sounds and egophony develop 1–3 days after onset of symptoms (i.e., cough and fever), and dullness to percussion (plus increased tactile fremitus) occurs even later. This time lag usually allows for x-ray to preempt diagnosis, thus making exam often irrelevant.
Wheezing: significance
Wheezing intensity does not correlate with severity of obstruction.
Only pitch and length of wheezes are useful predictors of airway narrowing. Higher-pitched and longer wheezes reflect worse obstruction.
Bowel sounds: utility in intestinal obstruction
Useless
Bowel sounds lack sensitivity and specificity for intestinal obstruction, being decreased or absent in only one quarter of cases. Hence, they are clinically useless.
Murphy’s sign: specificity and sensitivity
A painful arrest in inspiration triggered by palpation of the edge of an inflamed gallbladder (Murphy’s sign) is a good test for cholecystitis, with sensitivity and specificity of 50–80% (specificity usually a little higher than sensitivity).
Splenomegaly: interpretation
(1) + hepatomegaly: primary liver disease with portal hypertension;
(2) + lymphadenopathy excludes primary liver disease and makes instead hematologic or lymphoproliferative disorders more likely;
(3) massive splenomegaly: myeloproliferative etiology
Ascites volume detectable by physical exam
Combining all bedside maneuvers provides a good bedside tool for the diagnosis of ascites, with overall accuracy of 80%.
Volume necessary: (500–1000 mL) is much larger than that detected by ultrasound alone (100 mL).
Egophony
“EEE” sound will be heard as a “AH”
A better way to differentiate between the alveolar and interstitial causes of crackles is to test for the presence of egophony. When alveolar filling is present, the “EEE” sound will be heard as a “AH” sound; however, in interstitial lung disease the “EEE” sound will be preserved.
Wheezing in asthma
Polyhonic
The most frequent cause of wheezing is asthma, which results in polyphonic wheezing due to the dynamic variability in airway obstruction throughout the lung fields.
Absent breath sounds
severe bullous lung disease, emphysema, pneumothorax, or pleural effusion.
Stridor vs wheezing
Stridor is loudest during inspiration,
When compared to wheezing associated with small airway disease, stridor is loudest during inspiration, although it can be heard during expiration as well
Consolidation vs pleural effusion: difference in exam
Consolidation: vocal transmission increased
Dullness to percussion can be seen with consolidation, atelectasis, and pleural effusion. With consolidation, voice transmission is increased during expiration so that one may hear whispered pectoriloquy or egophony. However, in both pleural effusion and atelectasis, breath sounds are diminished and there is no augmentation of voice transmission. Although this patient could have either atelectasis or pleural effusion, the lack of tracheal deviation points to pleural effusion.
A 72-year-old male with a long history of tobacco use is seen in the clinic for 3 weeks of progressive dyspnea on exertion. He has had a mild nonproductive cough and anorexia but denies fevers, chills, or sweats. On physical examination, he has normal vital signs and normal oxygen saturation on room air. Jugular venous pressure is normal, and cardiac examination shows decreased heart sounds but no other abnormality. The trachea is midline, and there is no associated lymphadenopathy. On pulmonary examination, the patient has dullness over the left lower lung field, decreased tactile fremitus, decreased breath sounds, and no voice transmission. The right lung examination is normal. After obtaining chest plain film, appropriate initial management at this point would include which of the following?
Intravenous antibiotics
Thoracentesis
Bronchoscopy
Deep suctioning
Bronchodilator therapy
- subacute-onset dyspnea and an examination consistent with pleural effusion. Dullness to percussion can be seen with consolidation, atelectasis, and pleural effusion. With consolidation, voice transmission is increased during expiration so that one may hear whispered pectoriloquy or egophony. However, in both pleural effusion and atelectasis, breath sounds are diminished and there is no augmentation of voice transmission.
Although this patient could have either atelectasis or pleural effusion, the lack of tracheal deviation points to pleural effusion. Atelectasis would have to be of many segments to account for these findings, and such significant airway collapse would generally cause ipsilateral tracheal deviation.
Most appropriate next management step would be thoracentesis to aid in the diagnosis of the etiology and for symptomatic relief.
affects the abductor pollicis longus and extensor pollicis brevis tendons at the point where they pass through a fibro-osseous tunnel (the first dorsal compartment) at the styloid process of the radius.
- noninflammatory thickening of both the tendons and the tunnel
- common cause of wrist pain, particularly among women between the ages of 30 and 50 years of age.
de Quervain tendinopathy
Which test?
Finkelstein test for de Quervain tendinopathy
The examiner gently rotates the patient’s wrist ulnarly (arrow) while the patient’s fingers are folded over the thumb.
From Sheon, RP, Moskowitz, RW, Goldberg, VM, Soft Tissue Rheumatic Pain: Recognition, Management, Prevention. 3rd ed, Williams & Wilkins, Baltimore 1996.
Finkelstein’s test: grasp the thumb and ulnar deviate the hand sharply.
If sharp pain occurs along the _ _ de Quervain’s tenosynovitis is likely.
Which tendons are affected?
distal radius
If sharp pain occurs along the distal radius de Quervain’s tenosynovitis is likely.
abductor pollicis longus and extensor pollicis brevis tendons
Durkan’s test
- Examiner presses thumbs over carpal tunnel and holds pressure for 30 seconds.
- Positive: onset of pain or paresthesia in the median nerve distribution within 30 seconds.
Accuracy[edit]
Sensitivity: 87% to 91%
Specificity: 90% to 95%.
Localized monophonic wheeze
Foreign body
