XRAYS VRS EXAM – WINNING THE PATIENT’S TRUST

I hear a lot of clinicians say that they order unnecessary x-rays because patients demand them.  There are probably some situations where that is inevitable.  But before resigning yourself to role of taking your patients “order,” consider whether a more open communication approach might help.

For example, I found the Ottawa ankle rules to be impractical because patients always wanted the x-rays.  But then I started introducing the Ottowa ankle rules to patients before performing them.  The patients could see the logic of this approach and now it is rare for a patient to demand an unnecessary x-ray (though some inevitably do of course).

Patients almost always trust the physical examination, as long as it is explained to them and the physician is able to explain the evidence for it.

Take home points:

If you want patients to trust your physical examination, explain it to them

NEONATAL NEUROLOGIC EXAMINATION

Here is an outline of the neonatal neurologic examination followed by a listing of some reflexes that might be of value in demonstrating intact neurologic function.

 

GENERAL OBSERVATION/BEHAVIOR

 

CRANIAL NERVES

CN II – responds to light

CN III/IV/VI – vestibulo-ocular reflexes intact to cardinal directions of gaze

CN V – rooting reflex intact

CN VII – facial symmetry during crying

CN VIII – responds to sound

CN IX/X/XII – normal sucking

CN XI – sternocleidomastoid movement noted

 

MOTOR

Tone normal in all 4 extremities, no hypotonia, no hypertonia. Spontaneously moves all extremities.

 

REFLEXES

Symmetrical reflexes knee, ankle, biceps, triceps

 

SENSATION

Responds to touch in all 4 limbs

 

 

—-

PRIMITIVE REFLEXES

Primitive reflexes can be used to evaluate motor function in the neonate.  These are listed below:

 

Fetal position – After 36 weeks the fetus assumes a flexed position.  If the neonate is moved to extension, it will pull back to flexion. This lessons with time and is most present the first 48 hours after birth

 

Pull to sitting -the child will spontaneously open the eyes when pulled to a sitting position (fpnotebook.com)

 

Walking reflex – stand the baby up and he or she will exhibit a walking reflex

 

Rooting reflex – scratch the cheek and the baby will root for a nipple

 

Suckling reflex – front of tongue latches on finger/nipple, back of tingue massages it, pharynx/esophagus pulls on the finger.

 

Fencing reflex – turn head to the side, that arm extends and the opposite arm flexes above the head

 

Moro startle reflex – an abrupt drop causes the arms to outstretch and flex forward.

 

Swimmer’s (Gallant)- hold baby prone, stroke spine on one side, that side will flex

 

Crawling reflex – place baby prone, will try to crawl briefly.

 

Rotation test – hold baby up, rotate to one side, baby will turn head to that side

HAND MUSCLE AND TENDON CHART

Movement Muscle Nerve Nerve root Remarks
Thumb flexion IP FPL (flexor pollicis longus) Median (AIN branch) C8, T1
Finger flexion DIP 2/3 FDP (flexor digitorum profundus) Median (AIN branch) C8 In forearm the FDP is superficial to the FDS
Finger flexion DIP 3/4/5 FDP (flexor digitorum profundus) Ulnar C8 Digits 3,4,5 FDP are banded together.  Flexion of one flexes all. Hold the rest of the digit in extension during the exam
PIP flexion FDS (flexor digitorum superficialis) Median C7 Because FDP of digits 3-5 are linked, can examine one FDS by holding the other digits in extension.
Finger abduction Dorsal interossei Ulnar T1
Finger adduction Palmar interossei Ulnar T1
Thumb adduction ADP (Adductor Pollicis) Ulnar C8 Froment’s sign (pt holds paper tight between thumb and index, absent ADP, the distal thumb will flex)
Thumb palmar abduction APB (Abductor pollicis brevis) Median C8/T1 Also serves opposition.  Affected by carpal tunnel syndrome
Thumb radial abduction APL (Abductor pollicis longus) Radial (Posterior IO) C6C7 Unites with extensor pollicis brevis to form radial side of snuffbox
MCP extension digit 1 (thumb) EPL (extensor pollicis longus) Radial nerve (posterior interosseus branch) C7 On ulnar side of snuff box. Place hand on table, have patient lift thumb up
MCP extension digit 2 EI (extensor indicis proprius) Radial (deep radial) C7
MCP extension digits 2-5 EDC (extensor digitorum communis) Radial (deep radial) C7
MCP extension digit 5 EDM (extensor digiti minimi) Radial (posterior IO branch of deep radial) C7

HAND EXAMINATION TEMPLATE: FUNCTIONAL ANATOMY

 

VASCULAR

 

Palpation – “extremity warm”

 

Color – “healthy pink”

 

Pulses – radial pulse normal

 

Capillary refill < 2 seconds

 

 

 

NEUROLOGIC – MOTOR (AND MUSCULOTENDINOUS)

 

THUMB

 

FPL distal thumb flexion 5/5

 

ADP thumb apposition 5/5

 

APB palmar abduction 5/5

 

APL radial abduction 5/5

 

EPL thumb dorsal extension 5/5

 

 

 

FLEXORS

 

FDP distal phalanx flexion 5/5

 

FDS proximal phalanx flexion 5/5 (with DIP and other digits in extension)

 

 

 

EXTENSORS

 

EIP extension of forefinger proximal phalanx 5/5

 

EDC extension proximal phalanx 5/5

 

EDM extension 5th digit proximal phalanx 5/5

 

 

 

OTHER MUSCLES

 

IO finger adduction/abduction 5/5

 

 

 

WRIST

 

FCU wrist ulnar deviation 5/5

 

FCR wrist radial deviation 5/5

 

PL intact to palpation

 

ECRB wrist extension 5/5

 

ECU ulnar deviation/extension 5/5

 

 

 

NEUROLOGIC – SENSORY

 

ulnar – volar tip 5th digit nl

 

median – volar tip 2nd digit nl

 

radial – dorsal 1st webspace nl


PULSUS PARVUS ET TARDUS REVEALS FLOW PROBLEMS IN AORTIC STENOSIS

A lot of attention is paid to the murmur of aortic stenosis, and there are certainly some interesting and informative nuances to this examination from a diagnostic perspective. However, the pulse examination in one respect is actually even more informative.  It tells whether there is evidence of a problem with forward flow.

 

The classic pulse in aortic stenosis is termed “pulsus parvus et tardus.” Parvus is Latin for weak though it is not clear how specific this is as a physical diagnostic sign.  Patients vary in their pulse intensity.

 

“Tardus” is latin for slow or late. This is an important finding. Because the word is a cognate of tardy, most textbooks emphasize delay.  The original Latin apparently also means slow, and refers to a slow upstroke of the pulse itself.  This is where the “parvus” is worth preserving.  If a patient has a pulse contour that appears weak and prolonged then this is “parvus et tardus” and is a sign of impaired flow.

 

The delay is probably what is easiest to discern.  Listen to S1 at the apex and compare the palpated carotid pulse to the heart sounds.  Is there a delay?  If so, there is a significant flow limitation.  This delay can also be discerned by palpating the radial artery, as Yoshioka showed in 2010.

 

I would be curious to know whether having the patient exercise might bring out a flow problem that was previously subclinical.

 

Take home points:

Pulsus parvus et tardus reveals flow limitations in aortic stenosis.

PSYCHOGENIC SEIZURES

No signs are pathognomonic for psychogenic seizures, but the bedside differentiation is important because people with psychogenic seizures are often exposed to potentially harmful anti-epileptic treatments.

 

These signs only apply to patients with generalized convulsions.  We are looking for clues of volition, inconsistent with a generalized seizure:

 

Responsiveness – a patient with psychogenic seizures can sometimes be suggestible enough to cooperate with the exam during the event.  For example, I once held a bedside teaching session during a psychogenic event, explained the importance of tongue biting, then asked the patient to stick out the tongue so we could see whether she was biting her tongue.  She stuck the tongue out and earnestly moved her lips away to demonstrate tongue-biting.  Most cases are harder to diagnose.

 

Eyes closed – During an epileptic seizure the eyes are usually open.  During a psychogenic seizure they tend to be shut, often forcefully.

 

Nonrhythmic motor movements – During an epileptic seizure, motor movements go through a certain progression, the classic being tonic then clonic.  These are rhythmic and symmetrical.  A psychogenic seizure is variable, intermittent, sometimes nonrhythmic, with an emphasis on pelvic thrusting (Elvis sign).  Side to side movements are generally seen only with psychogenic seizures.

 

Vocalization – Before an epileptic seizure there might be stereotyped vocalization or a loud pitched cry, but this should not happen during the generalized convulsion. In psychogenic seizures, there might be vocalizations of crying and moaning during the convulsion.

 

Immediate return of consciousness – In psychogenic seizures we see immediate arousal. Postictal confusion indicates an epileptic seizure.

 

Specific signs of epileptic convulsion include cyanosis and stertorous (snoring) breathing. The patient with a seizure does not breathe during the event. The physician can feel under the nostril for signs of breathing in the patient suspected of having a psychogenic seizure. The back of the hand is sensitive for feeling a breath. Epileptic seizures often occur during sleep, whereas psychogenic seizures presumably would not.

 

None of these signs are considered 100% sensitive and specific.  But put together, the diagnosis can probably be made with a reasonable degree of certainty.

PHYSICAL DIAGNOSIS OF PELVIC FRACTURES

A 70 year old male presents after a fall with left hip pain.  The radiologist interprets the CT scan as revealing no fracture.  The patient is able to bear weight and is discharged home.  10 days later the patient presents with persisting pain and difficulty ambulating.  A fracture is now clearly seen in the inferior public ramus.  Looking back at the prior scan, a subtle fracture was actually visible 10 days prior.  You want to make sure this doesn’t happen to you again.  Can physical diagnosis help?

The pelvis is a complex three dimensional structure, but most parts are palpable from the outside.  In fact, physical examination for fractures performs much better than x-rays, with one study showing x-rays as 79% sensitive but physical examination rising to 96% (Duane 2008).

Press over the symphysis pubis as well as compressing the bilaterally iliac crests.  Check the acetabular integrity by compressing over the greater trochanter. Palpate the sacrum.  Grab the ischial tuberosity and try to shake it, checking for fractures of the pubic rami.  By the end of this examination, you will know exactly where the patient might have a fracture.  Such vigilence is rewarded with a 98% sensitivity and 94% specificity for fractures (McCormick 2003).

Some recommend digital rectal examination for coccygeal fractures, and this certainly is reasonable if there is coccygeal pain.  The hip is brought through a full range of motion including flexion, abduction, and internal and external rotation.

Not every trauma patient needs such a detailed pelvic bone examination, but if the patient is complaining of hip or pelvic pain then dive in, knowing that a good physical examination is MUCH better than a set of x-rays.

A few weeks later you see a patient with pelvic pain after a fall, and the tenderness is maximal when you manipulate the ischial tuberosity and symphysis pubis. You look at the CT scan focusing in on the pubic rami and indeed see what you are looking for- both rami are fractured.

Take home points:

-The pelvis is an external bone and all areas of the pelvis are accessible to palpation and compression.

-A thorough physical examination is highly sensitive for fractures (Sauerland 2004).

PSYCHOGENIC COMA AND MALINGERING: CHECK EYELIDS, COLD CALORICS

I have now heard several stories of prisoners faking a coma.  In one, he was intubated for a GCS of 8, and the first clue was that the television was mysteriously and seemingly autonomously rotated toward the patient.  Eventually they lay a trap involving blocking access to the television, and were able to catch him in the act.

Patients do of course lie to us, but many patients have psychogenic coma, where they are not intentionally fabricating the coma, which arises from psychological distress and is termed a conversion reaction.  How can physical diagnosis demonstrate to us that a patient is actually awake?

The oculocephalic (doll’s eye) responses can give either fixed eyes or reflex responses in these patients.  However, the cold caloric oculovestibular reflexes are thought to be highly sensitive and specific, though they appear not to have been studied in this population.  Irrigate an ear with 60-100mL of ice water.  A patient in a true coma with an intact brainstem shows a slow tonic deviation of the eye toward the ice. Patients with damage to the brainstem show no response.  A patient who is awake shows fast phase nystagmus away from the cold ear.

Plum and Posner write “it is the presence of normal nystagmus in response to caloric testing that firmly indicates that the patient is physiologically awake and that the unresponsive state cannot be caused by structural or metabolic disease of the nervous system.” Later on they do qualify this statement by suggesting that intense visual fixation might overcome this nystagmus in some situations.

Other findings that are not consistent with organic disease include resistance to eye opening and rapid/active eye closure once released.  Coma findings that cannot be fabricated include the slow smooth closure of opened eyelids and roving eye movements.

Apparently the rolling upward of the eyeballs upon lid opening is a voluntary act, though I have not been able to find a citation for that.  Dropping the arm on the face is commonly used, and usually helpful, though I have seen it give a misleading result.  With a thorough history and examination, the hope is that the diagnosis will become more clear.

Take home points:

Fast nystagmus away from the ice indicates an awake patient

Resistance to eye opening and active eye closure suggests an awake patient

References:

Plum and Posner The Diagnosis of Stupor and Coma. This is a classic text that is highly recommended.

TEMPLATE: NEUROLOGICAL MENTAL STATUS EXAMINATION

 

FUNCTIONAL ANATOMY TEMPLATE: NEUROLOGICAL MENTAL STATUS EXAMINATION

 

Having a structured, systematic approach to the neurological mental status examination can greatly improve our diagnostic acumen.  Because this examination is long and complex, it helps to have a template. Unlike the mini-mental status examination, this template is organized by functional anatomy.

 

 

  1. GLOBAL BRAIN FUNCTION
    1. Arousal – alert (lethargy = drifts off, obtunded = difficult to arouse, stupor = requires constant vigorous stimulation, coma = unarousable.  If you can’t remember this, just document what stimulation is necessary for arousal)
    2. Attention – counts the months backward, spells globe backward (a problem with attention means delirium, assuming no dementia)
    3. Orientation – year, month, date, situation
  2. LOCAL BRAIN FUNCTION
    1. Frontal – no kinetic apraxia (test rock, paper, scissor), no disinhibition (naming Fs)
    2. Temporal
      1. Memory – 5 minute recall (note whether memory jogging required)
      2. Language – Naming items nl, receptive and expressive language nl (can test visual comprehension with reading aloud).  Test writing if you are unclear on aphasia vrs dysarthria.
    3. Parietal
      1. Constructional praxis – nl copy of cube, nl clock drawing
      2. Right inferior parietal lobe (+/- left): Double simultaneous stimulation – can check visual, tactile
      3. Left parietal: math (subtracting 7 from 100 serially)

 

 

References: Strub and Black’s The Mental Status Examination in Neurology

TEMPLATE: THE PSYCHIATRY EXAM

Here is a template that helps one document encounters with psychiatric overtones.  I included pertinent negatives that help prompt one to use the right terms.  These can be deleted during actual encounters.  Although I hear many express less enthusiasm for psychiatric emergencies, I believe that being able to systematically assess a patient’s psychiatric state goes a long way toward understanding the difficult patient encounter.

 

Arousal: Alert

Attentiveness: fully attentive

Appearance: well-dressed and well-groomed

Attitude: cooperative, not guarded

Activity: calm, not restless, no abnormal movements, good eye contact

Orientation: Fully oriented

Mood: euthymic, not dysphoric, euphoric, apathetic, anxious or angry

Affect: normal range, not restricted, flat, or labile

Verbal: nl expressive and receptive language function

Thought process: organized, goal-directed. Pt did not require redirection.

Thought content: no delusions, no suicidal/homicidal ideation

Perceptions: not responding to internal stimuli

Insight/Judgment: good insight, judgment appears to be good

 

 

References for this include Trzepacz’ excellent textbook, The Psychiatric Mental Status Examination.