AAA Rational Clin Exam Handbook

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A Concise, but Rational,Approach to the Clinical Exam

A Summary of the JAMA Rational Clinical Exam Series

Sammy H. Ali and Douglas Wright

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Table of Contents

Evidence Based Medicine Basics .......................................................................................2

Respiratory EvaluationPulmonary Embolus .............................................................................................................3

Deep Vein Thrombosis..........................................................................................................3Airflow Limitation.................................................................................................................4

Cardiovascular EvaluationPeripheral Arterial Disease ....................................................................................................5

Cardiac Tamponade .............................................................................................................5Aortic Dissection..................................................................................................................6

Abdominal Aortic Aneurism ...................................................................................................7Congestive Hearth Failure.....................................................................................................7

Myocardial Infarction............................................................................................................8Systolic Murmurs (AS, MR, TR)..............................................................................................10

Aortic Regurgitation .............................................................................................................12Jugular Venous Pressur ........................................................................................................13

Hypovolemia.......................................................................................................................14

Carotid Bruits......................................................................................................................15Abdominal Bruits .................................................................................................................15

Abdominal EvaluationAscites ...............................................................................................................................16

Splenomegaly .....................................................................................................................17Acute Cholecystitis...............................................................................................................18

Appendicitis ........................................................................................................................19Acute Abdominal Pain Management........................................................................................19

Hepatomegaly.....................................................................................................................20Dyspepsia...........................................................................................................................20

Musculoskeletal EvaluationOsteoporosis.......................................................................................................................21

Neurological EvaluationStroke................................................................................................................................22

Myasthenia Gravis ...............................................................................................................23Temporal Arteritis................................................................................................................24Parkinsons Disease .............................................................................................................25

Migraine .............................................................................................................................26Vertigo...............................................................................................................................27

Carpal Tunnel......................................................................................................................27

Infectious Disease EvaluationAcute Meningitis ..................................................................................................................29

Influenza ............................................................................................................................30Urinary Tract Infection .........................................................................................................31

Septic Arthritis ....................................................................................................................32Sinusitis .............................................................................................................................33

General Patient Safety Evaluation

Depression .........................................................................................................................34Patient Falls ........................................................................................................................34Alcohol Abuse .....................................................................................................................34

Additional EvaluationBreast Cancer .....................................................................................................................35Thyroid Goiter .....................................................................................................................35

Clubbing.............................................................................................................................36Melanoma...........................................................................................................................36

FHx of Cancer .....................................................................................................................37Penicillin Alllergy .................................................................................................................38

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Evidence Based Medicine Basics

Definitions

Sensitivity: Proportion of Patients with the condition that have a positive result. When a sign, test or symptom

has a high sensitivity, a negative result rules out the diagnosis(SnOUT sensitivity can be used to rule OUT a Dx).

Specificity: Proportion of Patients that do not have the condition that have a negative/absent result. When a

sign, test or symptom has an extremely high specificity (say, over 95%), a positive result tends to rule in the

diagnosis

(SpIN specificity can be used to rule IN a Dx).

Positive Predictive Value: Proportion of people with a positive test who have the target disorder

Negative Predictive Value: Proportion of people with a negative test who do not have the target disorder

Positive Likelihood Ratio: the likelihood that a positive result would be expected in a patient with the target

condition compared to the likelihood that that same result would be expected in a patient without the condition.

Negative Likelihood Ratio: the likelihood that a negative result would be expected in a patient with the target

condition compared to the likelihood that that same result would be expected in a patient without the condition.

2 x 2 Table Graphical Explanation of Above Application of Likelihood Ratios: The Nomogram

sensitivity = a/(a+c)

specificity = d/(b+d)

likelihood ratio (LR+) = sensitivity / (1-specificity)

likelihood ratio (LR-) = (1-sensitivity) / specificity

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Respiratory Evaluation

Pulmonary EmbolismDoes This Patient Have Pulmonary Embolism?

Sanjeev D. Chunilal; John W. Eikelboom; John Attia; Massimo Miniati; Akbar A. Panju; David L. Simel; Jeffrey S. Ginsberg

JAMA 2003; 290: 2849-2858.

Clinical Results:

Pretest Probability and Related Probability of having a PE based on different methods of clinical assessment.

Clinical Gestalt Clinical Rules

Low 8-19% 3-28%

Moderate 26-47% 16-46%

High 46-91% 38-98%

Bottom Line:

Clinical Prediction rules have similar accuracy to the clinical gestalt of experienced clinicians. For the

inexperienced, it is advised to use the rules to categorize patients into low, moderate and high probabilities.

Clinical Rules:

Deep Vain ThrombosisDoes This Patient Have Deep Vein Thrombosis?

Philip S. Wells; Carolyn Owen; Steve Doucette; Dean Fergusson; Huyen Tran. JAMA, January 11, 2006; 295: 199 - 207.

Clinical Results:

-Prevalence of DVT: low risk- 5.0%, moderate risk- 17%, and high risk- 53%

-Wells Pretest Probability Model only validated for outpatients, NOT hospitalized pts

-D-Dimer Sen, Spec, -LR: low risk- 88%, 72%, 0.18, moderate risk- 90%, 58%, 0.19, high risk- 92%, 45%, 0.16

-High pretest probability pts have low specificity with D-dimer; therefore, do NOT use as screening test

Bottom Line:Estimation of the pretest probability of DVT improves diagnostic accuracy. If the pretest probability is low

and the D-dimer is negative, DVT can be ruled-out; however, a high pretest probability requires diagnostic

testing to rule-out DVT.

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Clinical Rules: Evidence:

Airflow limitationDoes the clinical examination predict airflow l imitation?

Donald R. Holleman Jr., David L. Simel

JAMA. 273(4):313-9, 1995 Jan 25.

Clinical Results:

Increased probability of airflow limitation

-Presence of either wheezing (+LR 36, spec 99.6%) or barrel chest (+LR 10, spec 99%) virtually rules in

airflow limitation.

-Presence of decreased cardiac dullness (+LR 10), hyperresonance on percussion (+LR 4.8) or rhonchi (+LR

5.9) are highly suggestive as well.

Decreased probability of airflow limitation

-No single item or combination of items from the clinical exam rules out airflow obstruction.

-The best finding associated with decreased likelihood is a negative history of smoking (-LR 0.16), especially in

the absence of wheezing.

Evidence:

Historical Finding +LR -LR

Smoking: >70 vs 1/4 cup 4 0.84

Symptoms of chronic bronchitis 3 0.78

Wheezing 3.8 0.66

Coughing 1.8 0.69

Any Dyspnea 1.2 0.55

Physical Finding +LR -LR

Wheezing 36 0.85

Barrel chest 10 0.9

Decreased cardiac dullness 10 0.88

Match test 7.1 0.43

Rhonchi 5.9 0.95

Hyper-resonance 4.8 0.73

Subxyvoid cardiac impulse 4.6 0.94

Pulsus paradoxus 3.7 0.62Decreased breath sounds 3.7 0.7

Accessory muscle use - 0.7

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Cardiovascular Evaluation

Peripheral Arterial DiseaseDoes the Clinical Examination Predict Lower Extremity Peripheral Arterial Disease?

Nadia A. Khan; Sherali A. Rahim; Sonia S. Anand; David L. Simel; Akbar Panju. JAMA 2006; 295: 536-546.

Physical Exam:-Ankle-Brachial Index (ABI): Ratio of highest systolic BP of the ankle (dorsalis pedis and/or posterior tibialis)

divided by the brachial BP, most accurately taken with the pt supine and the cuff placed 2-3 cm above the

measured pulse detected by the hand-held Doppler. ABI

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Bottom Line:

Most patients with cardiac tamponade will have at least one sign/symptom and pulsus paradoxus is helpful, but

further testing is required for definite dx.

Evidence:

Table 1 - Sensitivity of the Physical Examination in the Diagnosis of Cardiac Tamponade

Sign Pooled Sensitivity %

Pulsus Paradoxus > 10mm Hg 85Tachycardia 77

Hypotension 26Hypertension (sys bp> 140) 33Tachypnea 80

Diminished Heart Sounds 28Elevated JVP 76

Peripheral Edema 21-28

Pericardial Rub 19-29Hepatomegaly 28-55Kussmaul Sign 26

Pulse Pressure, mm Hg>0>100

5412

Total Parodox 23

Cardiomegaly on CXR 89 (73-100)

ECG FindingsLow VoltageAtrial ArrythmiaElectrical Alternans

ST-segment elevationPR-segment depression

42 (32-53)6 (1-11)16-21

18-3018

Aortic DissectionDoes This Patient Have an Acute Thoracic Aortic Dissection?

Michael Klompas . JAMA, May 2002; 287: 2262 - 2272.

Clinical Results:

-Highest Sensitivities: sudden onset (84%) of severe pain (90%)

Increase the Probability of Aortic Dissection (+LR):

Blood pressure differential between arms (5.7), neurological deficits (6.6-33.0), Marfan Syndrome (4.1), tearingor ripping quality of pain (1.2-10.8), migratory pain (1.1-7.6)

Decrease the Probability of Aortic Dissection (-LR):

Absence of sudden onset of pain (0.3), no change in aorta or mediastinum on CXR (0.3)

Bottom Line:

The before mentioned findings alter the likelihood of an aortic dissection; however, these clinical and CXR

findings cannot be used to rule out the Dx due to its severe morbidity. The results must be accepted with

caution, as a prospective, blinded study has not been done.

Evidence:

Symptom or Sign Positive LR Negative LR

Hx of HTN 1.5 (1.2-2.0) 0.5 (0.3-0.7)

Sudden Chest Pain 1.6 (1.0-2.4) 0.3 (0.2-0.5)

Tearing/Ripping Chest Pain 1.2-10.8 0.4-0.99

Migrating Pain 1.1-7.6 0.6-0.97

Pulse deficit 5.7 (1.4-23.0) 0.7 (0.6-0.9)

Focal Neurological Deficit 6.6-33.0 0.71-0.87

Diastolic Murmur 1.4 (1.0-2.0) 0.9 (0.8-1.0)

Englarged Aorta or wide mediastinum 2 (1.4-3.1) 0.3 (0.2-0.4)

LVH 0.2-3.2 0.84-1.2

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Abdominal Aortic Aneurism (AAA)Does this patient have abdominal aortic aneurysm?

Frank A. Lederle, David L. Simel. JAMA. 281(1):77-82, 1999 Jan 6.

Physical Examination:

AAA palpation: patient supine with knees raised with relaxed abdomen, feel for aortic pulsation few cm

cephalad of umbilicus. Position hands on abdomen palms down and place index fingers on either side ofpulsating area to measure aortic width (normal aorta 5.0cm AAAs (+LR 15.6).

- Roughly 43% of AAAs found to be large on physical exam will be supported by ultrasound findings.

Bottom Line:

Abdominal exam will detect of AAAs that are large enough to warrant surgery, but cannot be relied upon to

exclude the diagnosis. Although a positive exam increases the likelihood of AAA diagnosis significantly,

roughly half of these cases will be excluded on U/S (safe and relatively inexpensive test).

Evidence:

Table 1: Accuracy of Abdominal Palpation for detecting AAA (using >3cm or >4cm cutoff point)

Cutoff Point >3.0cm Cutoff Point > 4.0cm

Positive LR Negative LR Positive LR Negative LR

12.0 (7.4-19.5) 0.72 (0.65-0.81) 15.6 (8.6-28.5) 0.52 (0.38-0.67)

*pooled results from numerous trials

Table 2: Sensitivity of Abdominal Palpation for detecting AAA of various diameters

3.0-3.9cm 4.0-4.9cm >5.0cm

Sensitivity 29% 59% 76%

*pooled results from numerous trials

Congestive Heart FailureDoes This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure?Charlie S. Wang; J. Mark FitzGerald; Michael Schulzer; Edwin Mak; Najib T. Ayas. JAMA, October 19, 2005; 294: 1944 - 1956.

Clinical Results:

Increase Probability CHF (+LR):Past hx of CHF (5.8), PND (2.6), CXR with pulmonary venous congestion (12) or interstitial edema(12),

S3 gallop (11), abdominojugular reflux (6.4), ECG with Afib (3.8)

Decrease Probability of CHF (-LR):

Absence of past Hx of CHF(0.45), rales (0.51), dyspnea on exertion (0.48), CXR cardiomegaly (0.33),

BNP

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Myocardial InfarctionIs this patient having a myocardial infarction?

Akbar A. Panju, Brenda R. Hemmelgarn, Gordon H. Guyatt, David L. Simel JAMA. 280(14):1256-63, 1998 Oct 14.

Background:

-Differential for ischemic cardiac pain includes non-ischemic cardiac ( i.e. pericarditis, aortic dissection) andnon-cardiac causes (i.e. GERD, PUD, pneumothorax, PE, MSK, panic attack).

-Diagnosis of MI is confirmed with ischemic ECG changes (STEMI vs. NSTEMI) and presence of cardiac

enzymes (CK/troponin)

Clinical Rules:

Increased probability of MI:

-Pain radiation to both left and right arms (+LR 7.1) is the best indicator that a patient is having an MI.

Hypotension (+LR 3.1), Right shoulder radiation (+LR 2.9) and pain in left arm (+LR 2.3) also all increases the

likelihood.

Decreased probability of MI:

Pleuritic chest pain, sharp/stabbing chest pain, positional chest pain, and reproducibility by palpation all reduce

the likelihood that a patient is having an MI.

Bottom Line:

Although diagnosis is made by EKG and blood chemistry, pretest probability can be dramatically affected by

radiation and quality of the chest pain.

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Evidence:

Is This Patient Dead, Vegetative, or Severely Neurologically Impaired?: Assessing Outcome for Comatose Survivors of Cardiac

ArrestChristopher M. Booth; Robert H. Boone; George Tomlinson; Allan S. Detsky. JAMA 2004; 291: 870-879.

Clinical Results:

Most predictive of death and poor neurological outcome-

At 24 hours: absent corneal reflexes, papillary response, withdrawal to pain, and motor response (also at 72hours)

*No clinical findings strongly predicted good outcome

Bottom Line:

The prognosis comatose survivors of cardiac arrest can be strongly predicted with simple physical exam

maneuvers, the most useful after 24 hours. Physical exam should not be used to provide treatment

recommendations or be used prior alone before 24 hours.

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Systolic MurmursDoes this patient have an abnormal systolic murmur?

Edward Etchells, Chaim Bell, Kenneth Robb. JAMA. 277(7):564-71, 1997 Feb 19.

Aortic Stenosis

Physical Examination:

Apical-carotid delay: simultaneously palpate PMI and right carotid artery for delay, which if present is

abnormal

Brachioradial delay: simultaneously palpate right brachial artery w/ R-thumb and r ight radial artery w/ left

fingers to detect a delay, which if present is abnormal

Valsalva Manuever: have patient strain against a closed g lottis (or sustained abdominal pressure) for 20sec and

note changes in murmur intensity. Valsalva decreases venous return and increases systemic arterial resistance,

decreasing intensity of AS murmur.

Clinical Results:

Increased probability of AS:

Presence of any of the following significantly increases likelihood of AS : slow rate of rise of carotid pulse

(+LR 130), peak murmur intensity in late or mid systole (+LR 8-100), decreased S2 intensity (+LR 50), apical-

carotid delay (+LR >2.4) and brachioradial delay (+LR 6.8).

Decreased probability of AS:

The absence of radiation to the r ight carotid significantly reduces likelihood of AS (-LR 0.05).

Evidence:

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Mitral Regurgitation

Physical Exam:

Transient Arterial Occlusion: Simultaneously inflate 2 BP cuffs around patients arms to approx. 20-40mmHg

above their systolic BP and check for change in murmur intensity. Increases systemic arterial resistence which

increases intensity of MR murmur.

- Alternatively can be done by having patient clench fists tightly, however no evidence supporting this method.

Clinical Results:

Increased probability of MR

Murmur location in the mitral area (+LR 3.9) and increase in murmor intensity with transient arterial occlusion

(+LR 7.5) increase likelihood of MR significantly.

Evidence:

Tricuspid Regurgitation

Physical Exam:

Quiet Inspiration: Determine effect of quiet inspiration (not deep breathing) on murmur intensityAbdominal Pressure: Patient exerts firm, sustained pressure inward and cephalad below right costal margin.

*these maneuvers increase R-sided venous return and therefore should increase TR murmur intensity.

Clinical Results:

Increased probability of TRBoth quiet inspiration (+LR 8, -LR 0.2) and abdominal pressure (+LR 2.5-infinity, -LR 0.33) significantly

increase likelihood that murmur is TR. Absence of these findings decreases likelihood.

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Aortic RegurgitationDoes this patient have Aortic Regurgitation?

Niteesh K. Choudhry and Edward F. Etchells JAMA. 281(23):2231-8, 1999 Jun 16.

Physical Exam:

Transient Arterial Occlusion: Simultaneously inflate 2 BP cuffs around patients arms to approx. 20-40mmHg

above their systolic BP and check for change in murmur intensity. Increases systemic arterial resistence which

increases intensity of AR murmur.

- Alternatively can be done by having patient clench fists tightly, however no evidence supporting this method.

Popliteal-Brachial pulse gradient (Hill sign): Systolic BP in lower extremities at least 20mmHg higher than

in arms while supine.

Flint Murmur: low-pitched late-diastolic apical murmur best heard w/ patient in left lateral decubitus using

bell of stethescope.

Clinical Results:

Increased probability of AR

- popilteal-brachial gradient > 20mmHg (+LR 8.2) and increased intensity with transient arterial occlusion (+LR

8.4) are both very predictive of AR if present

-presence of Flint murmur increases the likelihood of moderate-greater AR significantly (+LR 25)

*it appears are though neither peripheral hemodynamic signs and pulse pressure >50mmHg have little use in

ruling in or out AR.

-peripheral hemodynamic signs included are Deroziez bruit, femoral pistol shots and Corigan pulses

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Jugular Venous Pressure (JVP)Does this patient have abnormal central venous pressure?

Deborah Cook, David L. Simel JAMA. 275(8):630-4, 1996 Feb 28.

Multiphasic Waveform:

Physical Examination:

JVP:

-Well-lit room ( tangential lighting), angle patient usually 30-45

-Distinguish betweenJVP(biphasic wave, positional change, nonpalpable, occludable, positive abdominal-

jugular reflex) and carotid pulse (single sharp wave, no positional change, palpable, non-occludable, no

abdominal-jugular reflex)

-Measure vertical distance in centimeters from sternal angle of Louis to top of JVP; >4cm is elevated

Abdominojugular (Hepatojugular) reflux: Firm pressure (approx. 20-35mmHg) is applied w/ palm of hand to

midabdomen for 15-30sec. Positive test occurs when abdominal compression causes sustained increase of>4cm.

Clinical Results:

Is the central venous pressure high?

Assessment of a JVP as being high on clinical exam increases the likelihood of high central venous pressure by

4-fold (+LR 4.1), while assessment of a JVP as being low makes it very unlikely that central venous pressure is

high (-LR 0.2).

Abdominojugluar reflux significantly increases the likelihood that a patient has CHF if positive (spec 96%, +LR

6.4), however if negative does not have any ability to rule out the condition (sens 24%).

Bottom Line:

-Clinical assessment of a JVP as either high or low has good predictive value of the central venous pressure,however has little predictive value in describing normal CVP.

-Abdominojugular reflux is very useful in ruling in CHF if positive, but has little use in ruling it out if negative.

Evidence:

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HypovolemiaIs this patient hypovolemic?

Steven McGee, William B. Abernethy III, David L, Simel JAMA. 281(11):1022-9, 1999 Mar 17.

Physical Examination:

Orthostatic vitals- When measuring postural vitals clinician should wait 2 minutes before measuring supine vitals, and 1

minute after standing before measuring standing vitals.- Sitting instead of standing markedly decreases ability to detect hypovolemia due to blood loss.

Postural Pulse Increase is >30beats/min increase on standing

Postural Hypotension is >20mmHgdecrease of SBP on standing

Clinical Results:

Hypovolemia due to blood loss:-Postural Pulse increment > 30mmHg on standing and/or severe postural dizziness is both the most specific and

sensitive indicator of hypovolemia secondary to severe blood loss, therefore presence/absence of these signs is

sufficient to rule-in/rule-out the condition.

-Although presence of postural hypotension (>20mmHg drop in SBP on standing) is excellent at ruling-inhypovolemia secondary to severe blood loss, it adds little additional predictive value to the postural pulse +

postural dizziness combination.

Hypovolemia due to volume depletion (vomiting, diarrhea and decreased oral intake, but not blood loss):

-The presence of increased cap-refill time, dry axilla, sunken eyes and upper/lower extremity weakness are

useful for ruling in hypovolemia secondary to volume depletion.

-Absence of dry mucous membranes and lack of longitudinal furrows on tongue are powerful methods for

ruling out hypovolemia secondary to volume depletion.

Bottom Line:

-Presence of absence of a Postural Pulse increment > 30mmHg on standing and/or severe postural dizziness is

sufficient for ruling-in or ruling-out hypovolemia due to severe blood loss, however is less useful in mild blood

loss. Postural hypotension is less sensitive but also useful to help rule in.

-For other causes of hypovolemia (vomiting, diarrhea, decreased intake) increased cap-refill, dry axilla and

sunken-eyes are most useful to rule in and presence of moist mucous membrane most useful to rule out.

Evidence:

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Carotid BruitDoes this patient have a clinically important carotid bruit?

Jean-Stephane Suave, Andreas Laupacis, Truls Ostbye, Brian Feagan, David Sackett JAMA. 270(23):2843-5, 1993 Dec 15.

Physical Examination:

-It is conventional to use the bell of the stethoscope and listen for carotid bruits in area between thyroid

cartilage and jaw bilaterally.

Bottom Line:

-Although presence of carotid bruit in symptomatic patients increases likelihood that the stenosis is high grade,

accuracy is low.

-The presence of a carotid bruit cannot be used to either rule in or rule out surgically amenable carotid stenosis

in symptomatic patients.

Evidence:

Abdominal BruitsIs Listening for Abdominal Bruits Useful in the Evaluation of Hypertension?

J.M. Turnbull

JAMA. 274(16):1299-301, 1995 Oct 25.

Clinical Results:

-the absence of an abdominal bruits has very little utility in ruling out renovascular hypertension (Sens 39-77%)

-the presence of an abdominal bruit in hypertensive patients is suggestive of renovascular hypertension,

especially if the bruit is both systolic & diastolic (Spec 99%, +LR 39)

Evidence:

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Abdominal Evaluation

AscitesDoes this patient have ascites? How to divine f luid in the abdomen

John W. Willaims, Jr., David L. SimelJAMA. 267(19):2645-8, 1992 May 20

Background:

-Ascites becomes clinically detectable when >500ml.

Physical Exam:

-Bulging Flanks: inspection of abdomen for absence/presence of bulging flanks

-Flank Dullness: percussion of flanks for dullness

-Shifting Dullness: first percuss and map border between tympany and dullness with patient supine, then have

patient turn onto one side and percuss for new border. In ascitic abdomen dullness will shift to dependant

portion.

-Fluid Wave: Have patient/assistant press both hands firmly down midline of patients abdomen. Take one

flank sharply with fingertip and feel opposite flank for transmitted impulse.

Clinical Results:

Ruling in Ascites:-most powerful history findings are increased girth (+LR 4.16) and recent weight gain (+LR 3.2)

-most powerful physical exam finding is a positive f luid wave (+LR 6.0) and shifting dullness (+LR 2.7)

Ruling out Ascites:

-most useful history findings are negative histories of ankle swelling (-LR 0.10) or increased abdominal girth (-

LR 0.17)

-most useful physical exam finding are lack of bulging flanks (-LR 0.3), flank dullness (-LR 0.3) or shifting

dullness (-LR 0.3)

Evidence:

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SplenomegalyDoes this patient have splenomegaly?

Steven A. Grover, Alan N. Barkun, David L. Sackett. JAMA. 270(18):2218-21, 1993 Nov 10.

Physical Examination:

Castell's Sign: with patient in supine position, percuss lowest intercostal space at the left anterior axillary line

during inspiration and expiration. In presence of splenomegaly percussion will remain dull during inspiration.

Traube's Space: cresent-shaped space depicted by the following surface markings - the left sixth rib, the leftanterior axillary line, and the left costal margin. Dullness to percussion in this space indicates splenomegaly.

Palpation of spleen should begin in the right lower quadrant and proceed towards the left upper quadrant in

order to follow the path of splenic enlargement.

Clinical Results:

Decreased probability of splenomegaly:

-Castells sign (when negative) has the best ability to decrease probability of splenomegaly (Sens 82%),

followed by traubes space (Sens 78%). Palpation has very little predictive value if negative.

Increased probability of splenomegaly:

-Although castells and traubes can aid in ruling in sp lenomegaly, postive palpation has a very high likelihood

of indicating splenomegaly.

Bottom Line:

-Physical exam should begin with percussion (castells or traubes) and if there is no dullness there is no need to

proceed with palpation. (if suspicion is high enough then U/S should be used in this case)

-If percussion is dull then proceed with palpation. If both tests are positive then splenomegaly can effectively

be ruled-in.

Evidence:

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Acute CholecystitisDoes This Patient Have Acute Cholecystitis?

Robert L. Trowbridge; Nicole K. Rutkowski; Kaveh G. Shojania. JAMA 2003; 289: 80-86.

Physical Exam:

-Murphys Sign- on deep inspiration, the pt feels pain and arrests inspiration when the pressure is placed under the

right costal margin

Clinical Results:

Increase the Likelihood of Cholecystitis (+LR):

Murphy Sign (2.8)

Decrease the Likelihood of Cholecystitis (-LR):

Absence of Right Upper Quadrant Tenderness (0.4)

*Both CI include 1.0. No clinical or laboratory finding had sufficient LRs to rule in or rule out the Dx.

**Clinical Gestalt of experienced clinician: positive LR 25-30

Bottom Line:

Dx is dependent upon the combinations of factors synthesized by experienced clinicians and additional

diagnostic imaging.

Evidence:

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AppendicitisDoes this patient have appendicitis?

James M. Wagner, Paul McKinney and John Carperter. JAMA. 276(19):1589-94, 1996 Nov 20.

Physical Examination:

Rebound Tenderness: apply pressure to abdomen with flat of hand for 30-60sec and without warning remove

hand suddenly and observe for pain on removal

Rovsing Sign:press deeply in LLQ and release pressure suddenly positive sign is pain in RLQPsoas Sign: with patient supine, have them lift thigh against your hand placed just above their knee increased

pain with maneuver is positive sign.

Obturator Sign:passively flex the right hip + knee and internally rotate the leg at the hip increased pain with

maneuver is positive sign.

Clinical Results:

Increased probability of Appendicitis:

-most powerful history findings are classic migration of pain (+LR 3.2), RLQ pain (+LR 7.3) and pain before

vomiting (+LR 2.8)

-most powerful exam findings are rigidity (+LR 3.76), positive psoas and fever (+LR 1.94)

Decreased probability of Appendicitis:

-the absence of RLQ pain (-LR 0-0.28) and the presence of similar pain previously (-LR 0.323) are powerful

historical findings that make appendicitis less likely

Bottom Line:

-no finding on the clinical examination can effectively rule out appendicitis.

-presence of peritoneal signs (guarding, rebound, psoas, etc) are useful if present but not if absent

Acute Abdominal Pain ManagementDo Opiates Affect the Clinical Evaluation of Patients With Acute Abdominal Pain?

Sumant R. Ranji; L. Elizabeth Goldman; David L. Simel; Kaveh G. Shojania. JAMA 2006; 296: 1764-1774.

Clinical Results:Altered clinical findings were found in a number of studies; However, significant physical examination findings

(ex. Peritoneal signs) were not altered, leading to no significant changes in management or morbidity and

mortality.

Bottom Line:

Analgesia administration in management of abdominal pain does not have a negative impact on patient

outcome, although it can affect minor clinical signs.

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HepatomegalyPhysical Examination of the Liver

C. David Naylor. JAMA. 271(23):1859-65, 1994 Jun 15

Physical Examination:

-normal liver span

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Muskuloskeletal Evaluation

OsteoporosisDoes This Woman Have Osteoporosis?

Amanda D. Green; Cathleen S. Coln-Emeric; Lori Bastian; Matthew T. Drake; Kenneth W. Lyles. JAMA 2004; 292: 2890-2900.

Physical Exam:

-Wall-Occiput Distance- determine kyphosis, a pt stands straight with back and heels touching a wall and a line from

lateral corner of eye to superior junction of auricle is parallel to the floor, the distance between the occiput and wall is

measured. +ve= >0 cm

-Rib-pelvis distance- measure of lumbar fracture, pt s tands with arms stretched to 90 deg in front while the examiner

stands behind and determines the number of f ingers that fit between the inferior ribs and superior hip at the midaxillary

line

-Skinfold thickness- calipers used to measure the skin thickness on the back of the hand, often at the 4th

metacarpal

-Hand Grip Strength- maximal force recorded while the pt hands arms outstretched to the side

Clinical Results:

Increase the Likelihood of Osteoporosis (+LR):

Weight

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Neurological Evaluation

StrokeIs This Patient Having a Stroke?

Larry B. Goldstein; David L. Simel. JAMA 2005; 293: 2391-2402.

Physical Exam:Arm Drift- limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if si tting) or

45 degrees (if supine). Drift is scored if the arm falls before 10 seconds.

Clinical Results:

Increase the Probability of Stroke (+LR):

Presence of arm drift, acute facial paresis, and/or abnormal speech (5.5)

Decrease the Probability of Stroke (-LR):

Absence of all of arm drift, acute facial paresis, and abnormal speech (0.39)

*Neuroimaging is required to accurately discriminate between hemorrhagic and ischemic

*Mild increase (LR = 1.2) in early mortality with the existence of any combination of impaired consciousness,

hemiplegia, and conjugate gaze palsy*Agreement between the examiners in the Dx of Stroke varies with sign/symptom and can be improved with

standardized scoring systems (ex. NIH stroke scale)

Bottom Line:

Focus on the three before mentioned signs will increase the accuracy of stroke Dx and using standardized

scoring systems (ex. NIHSS) will increase precision between examiners and better direct prognosis and

treatment. Even with the use of the clinical signs, appropriate neuroimaging are required to better define the

stroke subtype and any potentially treatable causes.

Evidence:

Clinical Rules:

*NIH Stroke Scale available at: http://www.strokecenter.org/trials/scales/nihss.html

ABCD score to determine occurrance of a stroke following a TIA: A (age; 1 point for age >60 years), B (blood pressure; 1 point for hypertension at the acute evaluation), C (clinical features; 2 points for focal weakness, 1 for speech disturbance without weakness), and D (symptom duration; 1 point for 1059 minutes, 2 points for >60 minutes).

Total scores ranged from 0 (lowest risk) to 6 (highest risk). In a validation cohort of 378 patients with more recent TIAs, 7-day stroke risk

ranged from 0% in those with scores

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Myasthenia GravisDoes This Patient Have Myasthenia Gravis?

Katalin Scherer; Richard S. Bedlack; David L. Simel. JAMA 2005; 293: 1906-1914.

Physical Exam:

-Curtain sign- pt stares straight ahead without blinking while the examiner holds the other eye lid open,

resulting in the free eye lid increasing in ptosis

-Lid twitch sign- pt follows the examiner from the looking down position to eye level, resulting in a briefovershoot than ptosis of the eyelid

-Sleep test- pt left in dark room with eyes closed for 30 minutes

-Ice pack test- placement of a glove filled with crushed ice over a closed eye for 2 minutes

-Rest test- glove filled with cotton (placebo) over a closed eye for 2 minutes

-resolution of ptosis or >2mm improvement = +ve result

-Cover-uncover test- to test for extra-ocular weakness, one eye is covered and the uncovered eye will drift

upward and/or lateral gaze

-Peek Sign- demonstrates orbicularis oculi fatigue by having the patients gently close their eyes and aftercomplete initial apposition of the lid margins, they separate within seconds, showing the white of the sclera

-Anticholinesterase Tests- edrophonium or pyridostigmine most commonly used, results in symptom

improvement

Clinical Results:Increase the Probability of Myasthenia Gravis (+LR):

Peek sign (30), ice test (24), response to anticholinesterase meds (15), abnormal sleep tests (53) and prolonged

speech becoming unintelligible (4.5)

Decrease the Probability of Myasthenia Gravis (-LR):

Negative response to anticholinesterase meds (0.11)

Bottom Line:

Simple bedside tests, sign, and symptoms are valuable in the Dx.

Evidence:

Table 3. Clinical Signs and Symptoms and Results of Clinical Tests in the Prediction of MG

Sign/Symptom Positive LR (95% CI) Negative LR (95% CI)

Food in mouth after swallowing 13.0 (0.85-212.0) 0.70 (0.58-0.84)

Unintelligible Speech after prolonged speaking 4.5 (1.2-17.0) 0.61 (0.46-0.80)

Peek Sign 30.0 (3.2-278.0) 0.88 (0.76-1.0)

Quiver eye movements 4.1 (0.22-75.0) 0.82 (0.57-1.2)

Ice Test 24.0 (8.5-67.0) 0.16 (0.09-0.27)

Anticholinesterase Test 15.0 (7.5-31.0) 0.11 (0.06-0.21)

Rest Test 16.0 (0.98-261.0) 0.52 (0.29-0.95)

Sleep Test 53.0 (3.4-832.0) 0.01 (0.00-0.16)

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Temporal ArteritisDoes This Patient Have Temporal Arteritis?

Gerald W. Smetana; Robert H. Shmerling. JAMA, Jan 2002; 287: 92 - 101.

Clinical Results:

Increase the Probability of Temporal Arteritis (+LR):

Hx of jaw claudication (4.2) or diplopia (3.4) and findings of artery beading (4.6), prominence (4.3) and

tenderness (2.6)

Decrease the Probability of Temporal Arteritis (-LR):

Absence of temporal artery abnormality (0.53) and normal ESR (0.2)

Bottom Line:

Only a few clinical findings and a normal ESR significantly change the LR of a positive biopsy. Thus, it is

clinician that must integrate the entire clinical picture to select the most likely pt for therapy and diagnosis.

Evidence:

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Parkinson DiseaseDoes This Patient Have Parkinson Disease?

Goutham Rao; Laura Fisch; Sukanya Srinivasan; Frank D'Amico; Tadao Okada; Carolyn Eaton; Craig Robbins. JAMA 2003; 289:347-353.

Clinical Results:

Increase the Probability of Parkinsons Disease (+LR):

History of tremor (1.3-17), combination of rigidity and bradykinesia (4.5), loss of balance (1.6-6.6),micrographia (2.8-5.9), shuffling gait (3.3-15), trouble with certain tasks such as turning in bed (13), opening

jars (6.1), and rising from a chair (1.9-5.2) and the glabellar tap test sign (4.5).

Decrease the Probability of Parkinsons Disease (-LR):

History of combination of rigidity and bradykinesia (0.12), symptomatic tremor (0.24-0.60), loss of balance

(0.29-0.35), and trouble with opening jars (0.26) and glabellar sign (0.13)

Bottom Line: Multiple features of history are useful to increase the pretest probability of Parkinsons, although

minimal signs have been proven.

Evidence:

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MigraineDoes This Patient With Headache Have a Migraine or Need Neuroimaging?

Michael E. Detsky; Devon R. McDonald; Mark O. Baerlocher; George A. Tomlinson; Douglas C. McCrory; Christopher M.

Booth. JAMA, September 13, 2006; 296: 1274 - 1283.

Clinical Results:

Features that Increase the Likelihood of Migraine (+LR):Containing four of five migraine features from the mnemonic POUNDing {Pulsating, duration of 4-72 hOurs,

Unilateral, Nausea, Disabling} (24), three of f ive features (3.5)

Features that Increase the Likelihood of Migraine versus Tension Headache (+LR):

Nausea (19), photophobia (5.8), phonophobia (5.2), exacerbation with physical activity (3.7)

Features that Decrease the Likelihood of Migraine versus Tension Headache (-LR):

Absence of Nausea (0.19), photophobia (0.24), phonophobia (0.38), exacerbation with physical activity (0.24)

Features that Increase the Likelihood that Neuroimaging is required (+LR):

Cluster-type headache (10.7), abnormal neurological examination (5.3), undefined headache (3.8), headache

with aura (3.2)

*No findings were strong enough to rule-out serious pathology

Bottom Line:

Migraine can be Dx with at least 4 of 5 historical features of POUNDing and differentiated from tension

headache with other features. Pts with features mentioned above should be imaged as they may be warning

signs of serious intracranial pathology.

Evidence:

Table 4. Pooled likelihood of significant abnormality on Neuroimaging

Clinical Feature Positive Likelihood Ratio

(95% CI)

Negative Likelihood Ratio

(95% CI)

Cluster-type headache 11 (2.2-52) 0.95 (0.84-1.1)

Abnormal Findings on Neurological

Examination

5.3 (2.4-12) 0.71 (0.60-0.85)

Undefined headache 3.8 (2.0-7.1) 0.66 (0.44-0.97)

Headache with Aura 3.2 (1.6-6.6) 0.51 (0.24-1.1)

Headache with Focal Symptoms 3.1 (0.37-25) 0.79 (0.51-1.2)

Headache Aggravated by Exertion or

Valsalva

2.3 (1.4-3.8) 0.70 (0.56-0.88)

Headache with Vomiting 1.8 (1.2-2.6) 0.47 (0.29-0.76)

Worsening Headache 1.6 (0.23-10) 1.0 (0.78-1.2)

Male Sex 1.3 (0.89-1.8) 0.86 (0.68-1.1)

Quick-onset Headache 1.3 (0.33-5.1) 0.79 (0.14-4.4)

New-onset Headache 1.2 (0.74-2.0) 0.89 (0.63-1.3)

Headache with Nausea 1.1 (0.87-1.3) 0.86 (0.63-1.2)Increased Headache Severity 0.83 (0.54-1.3) 1.2 (0.91-1.4)

Migraine-type Headache 0.55 (0.28-1.1) 1.2 (0.84-1.7)

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VertigoDoes this dizzy patient have a serious form of vertigo?

David A. Froehling, Marc D. Silverstein, David N Mohr, Charles W. Beatty. JAMA. 271(5):385-8, 1994 Feb 2.

Physical Examination:

Dix-Hallpike Manuever: begin with patient sitting with eyes fixed on examiners forhead. Firmy graph

patients head and have them quickly lie supine with head turned about 30 to one side and 30 below theexamining table observe for nastagmus. Repeat with head tilt to opposite side.

Clinical Results:

-Combination of a positive head-hanging maneuver plus either vertigo or vomiting has a high likelihood (LR =

7.6) of being peripheral vertigo.

Carpal Tunnel SyndromeDoes this patient have Carpal Tunnel Syndrome?

Christopher A. DArey and Steven McGee JAMA. 283(23):3110-7, 2000 Jun 21.

Physical exam:

Katz Hand Diagrams:Classic Pattern Probable Pattern Unlikely Pattern

Tinel Sign: paresthesias in median nerve distribution when clinician taps on distal wrist crease over median

nerve

Phalen Sign:paresthesias in median nerve distribution when patient flexes both wrists at 90 for 60sec

Flick Sign: Patient demonstrates flicking motion of hand (similar to shaking a thermometer) as response to

question what do you do with your hands when the symptoms are the worst?

Square Wrist Sign: ratio of anteroposterior dimension of wrist to mediolateral dimension > 0.70 when

measured at distal wrist crease

Closed first Sign:paresthesias in median nerve distribution when patient flexes fingers in closed fist for 60sec

Pressure Provacation:paresthesias in median nerve distribution when examiner presses palmar aspect of

patients wrist with their thumb for 60sec

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Tourniquet Test:paresthesias in median nerve distribution when blood pressure cuff is inflated around

patients arm for 60sec.

Clinical Results:

Increased probability of CTS

Findings favoring electrodiagnosis of CTS were hypalgesia (decreased sensitivity to pain) in median territory

(+LR 3.1), classic of probable Katz hand diagram results (+LR 2.4) and weak thumb abduction (+LR 1.8)

*Flick sign, closed fist sign and square sign show promise but require additional studies

Decreased probability of CTS

Findings arguing against electrodiagnosis of CTS were Katz hand diagrams classified as unlikely (LR 0.2) and

normal thumb abduction strength (LR 0.5)

Bottom Line:

The following findings had no value in diagnosis of CTS: Tinels sign and Phalens sign., patients age,

presence of nocturnal or bilateral symptoms, thenar atrophy, pressure provocation test, and the tourniquet test.

Evidence:

Table 1 Diagnostic Accuracy of History / Physical Examination for CTS

Finding Positive LR Negative LRClosed fist Sign 7.3 (1.1-49.1) 0.4 (0.2-0.7)

Hypalgesia 3.1 (2.0-5.1) 0.7 (0.5-1.1)

Flick Sign 21.4 (10.8-42.1) 0.1 (0.0-0.1)

Square Wrist Sign 2.7 (2.2-3.4) 0.5 (0.4-0.8)

Classic or Probable Katz Hand Diagram 2.4 (1.6-3.5) 0.5 (0.3-0.7)

Thenar atrophy 2.2 (0.7-6.7) 0.7 (0.5-1.1)

Weak thumb abduction 1.8 (1.4-2.3) 0.5 (0.4-0.7)

Tinel Sign 1.4 (1.0-1.9) 0.8 (0.6-1.1)

Phalen Sign 1.3 (1.1-1.6) 0.7 (0.6-0.9)

Nocturnal paresthesia 1.2 (1.0-1.4) 0.7 (0.5-0.9)

Pressure Prevocation 1.0 (0.8-1.3) 1.0 (0.9-1.1)

Tourniquet Sign 1.0 (0.5-1.9) 1.0 (0.7-1.5)

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Infectious Disease Evaluation

Acute MeningitisDoes this adult patient have acute meningitis?

John Attia, Rose Hatala, Deborah J. Cook, Jeffery C. Wong JAMA. 282(2):175-81, 1999 Jul 14.

Physical Examination:Nuchal Rigidity: rigidity on gentle forward flexion of neck of supine patient.

Kernigs Sign: with patient positioned supine with hip flexed 90, extension of knee joint elicits either stiffness

or pain in the lower back or thigh.

Brudzinskis Sign: passive flexion of the neck of supine patient results in flexion of the hip and knee joints.

Clinical Results

Ruling in meningitis:

-Kernigs and Brudzinski are useful for ruling in meningitis if positive (specificity 100%), but not very useful for

ruling out meningitis if not present (sensitivity 9%)

Ruling out meningitis:

Absence of all 3 classic signs (fever, neck s tiffness and altered mental status) makes diagnosis of meningitis

extremely unlikely-Absence of fever (sensitivity 85%) is the strongest physical sign for ruling out meningitis with absence of neck

stiffness (sensitivity 70%) or altered mental status (sensitivity 67%) also being useful.

Bottom Line:

Diagnosis of meningitis is virtually eliminated in the absence of any of the three classic features of fever, neck

stiffness or altered mental status (sensitivity 99%), and very unlikely if patient does not have at least two of

these features (sensitivity 95%).

Evidence:

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How Do I Perform a Lumbar Puncture and Analyze the Results to Diagnose Bacterial Meningitis?Sharon E. Straus; Kevin E. Thorpe; Jayna Holroyd-Leduc. JAMA 2006; 296: 2012-2022.

Clinical Results:

-Atraumatic versus standard needle and early mobilization did not show a significant decrease headache

-Reinsertion of stylet prior to needle withdrawal decreased headache

-Most accurate laboratory values to rule in bacterial meningitis is a CSF-blood glucose ratio of 0.4 or less (18),

WBC in CSF over 500/mcL (15), and CSF lactate of 3.5 mmol/L or more (21).

Bottom Line:

Focus on the before mentioned CSF values of Dx of bacterial meningitis. Bed rest after LP is not of use,

atraumatic needles may decrease headaches, and reinsertion of the stylet should be done on needle withdrawal.

Evidence:

InfluenzaDoes This Patient Have Influenza?

Stephanie A. Call; Mark A. Vollenweider; Carlton A. Hornung; David L. Simel; W. Paul McKinney. JAMA 2005; 293: 987-997.

Clinical Results:

-Age is essential for using clinical findings to influence the chance of a correct Dx.

Increase the Probability of Influenza (+LR):

*Decrease the LR: absence of cough (0.42), fever (0.4), nasal congestion (0.49) and presence of sneezing (0.49, if

>60 yo)

Decrease the Probability of Influenza (-LR):

*Increase the LR if over 60: fever, cough, and acute onset (5.4), fever and cough (5.0), and fever alone (3.8),

malaise (2.6), and chills (2.6)

Bottom Line:

Clinical findings are not accurate at identifying influenza and should be used in conjunction withepidemiological evidence to enhance Dx accuracy then treat empirically or with the confirmation of the rapid

influenza test.

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Urinary Tract InfectionDoes This Woman Have an Acute Uncomplicated Urinary Tract Infection?

Stephen Bent; Brahmajee K. Nallamothu; David L. Simel; Stephan D. Fihn; Sanjay Saint . JAMA, May 2002; 287: 2701 2710.

Clinical Results:

Increase the Probability of UTI (+LR):Dysuria (1.5), frequency (1.8), hematuria (2.0), CVA tenderness (1.7), back pain (1.6), combinations of dysuria

and frequency, but no vaginal discharge or irritation (24.6), self diagnosis of recurrent UTIs (4.0)

Decrease the Probability of UTI (-LR):

Absence of back pain (0.8) or dysuria (0.5), hx of vaginal discharge (0.3) or vaginal irritation (0.2), and vaginal

discharge on PE (0.7)

Bottom Line:

A pt presenting with one or more urinary symptoms has a 50% probability of the Dx and when used in specific

combinations, history can effectively rule-in the Dx; however, if symptoms are present, Hx, PE, and urinalysis

cannot rule-out the Dx.

Evidence:Table 2. Clinical Signs and Symptoms in the Prediction of Urinary Tract Infection

Symptom/Sign Positive LR (95% CI) Negative LR (95% CI)

Dysuria 1.5 (1.2-2.0) 0.5 (0.3-0.7)

Frequency 1.8 (1.1-3.0) 0.6 (0.4-1.0)

Hematuria 2.0 (1.3-2.9) 0.9 (0.9-1.0)

Fever 1.6 (1.0-2.6) 0.9 (0.9-1.0)

Flank Pain 1.1 (0.9-1.4) 0.9 (0.8-1.1)

Lower Abdominal Pain 1.1 (0.9-1.4) 0.9 (0.8-1.1)

Vaginal Discharge 0.3 (0.1-0.9) 3.1 (1.0-9.3)

Vaginal Irritation 0.2 (0.1-0.9) 2.7 (0.9-8.5)

Back Pain 1.6 (1.2-2.1) 0.8 (0.7-0.9)

Self-Diagnosis 4.0 (2.9-5.5) 0.0 (0.0-0.1)

Vaginal Discharge on PE 0.7 (0.5-0.9) 1.1 (1.0-1.2)

CVA tenderness on PE 1.7 (1.1-2.5) 0.9 (0.8-1.0)

Dipstick Urinalysis

(positive= +nitrite and leuks,

negative= -nitrites and leuks)

4.2 0.3

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Septic ArthritisDoes This Adult Patient Have Septic Arthritis?

Mary E. Margaretten; Jeffrey Kohlwes; Dan Moore; Stephen Bent. JAMA, April 4, 2007; 297: 1478 - 1488.

Clinical Results:

*Risk Factors: age, DM, RA, joint Sx, hip or knee prosthesis, skin infection, HIV (85% Sensitivity)

*Most Sensitive Clinical Findings: Joint Pain (85%), hx joint swelling (78%), fever (57%)

Increase the Likelihood of Septic Arthritis (+LR):

Increase with WBC count ( >25 000, LR 2.9, > 50 000 LR 7.7, >100 000, LR 28.0), % PMN >90% (3.4), the

presence of joint prosthesis and skin infection (15.0), recent joint injury (6.9)

Decrease the Likelihood of Septic Arthritis (-LR):PMN100 000/L 29 99 28.0 (12.0-66.0) 0.71 (0.64-0.79)

WBCs >50 000/L 62 92 7.7 (5.7-11.0) 0.42 (0.34-0.51)

WBCs >25 000/L 77 73 2.9 (2.5-3.4) 0.32 (0.23-0.43)

Polymorphonuclear cells 90% 73 79 3.4 (2.8-4.2) 0.34 (0.25-0.47)

Low glucose* 51 85 3.4 (2.2-5.1) 0.58 (0.44-0.76)

Protein >3.0 g/dL 48 46 0.90 (0.61-1.30) 1.10 (0.76-1.60)

LDH >250 U/L 100 51 1.9 (1.5-2.5) 0.10 (0.00-1.60)

Abbreviations: CI, confidence interval; LDH, lactate dehydrogenase.

*Defined in the different studies as serum/synovial fluid glucose ratio of less than 0.5 or 0.75, synovial fluid glucose level of

less than 1.5 mmol/mL, or both. To convert synovial fluid glucose to g/dL, divide by 0.0555.

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SinusitisDoes this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination

John W. Williams Jr., David L. Simel JAMA. 270(10):1242-6, 1993 Sep 8.

Clinical Results:

-The independent predictors for sinusitis are maxillary toothache, poor response to nasal decongestants, abnormal transillumination andcoloured discharge.

-When found alone are neither sensitive nor specific for sinusitis they must be combined to have any predictive value.

Bottom Line: *Combination of all independent predictors mentioned above increases the likelihood of sinusitis sharply (LR=6.4), while

having none of these predictors or only one in isolation virtually rules out sinusitis.Evidence:

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General Patient Safety Evaluation

DepressionIs This Patient Clinically Depressed?

John W. Williams Jr; Polly Hitchcock Nol; Jeffrey A. Cordes; Gilbert Ramirez; Michael Pignone . JAMA, Mar 2002; 287: 1160 - 1170.

Clinical Rules:-numerous studies of 1 to 5 minute screening tests had average PLR 3.3 and 0.19 NLR

-no significant difference between tools

-high agreement in Dx of major depression between psychiatrists and Family Physicians

Bottom Line:

Questionnaires are a reasonable starting point, but diagnostic confirmation by mental health professionals or

family physicians should be done.

Patient FallsWill My Patient Fall?

David A. Ganz; Yeran Bao; Paul G. Shekelle; Laurence Z. Rubenstein. JAMA, January 3, 2007; 297: 77 - 86.

Clinical Results:

-Baseline Pretest for age>65 27%-Highest LRs: fall in past year (2.3-2.8) and detectable gait abnormalities (1.72.4)

-No consistent effect: visual impairment, medication variables, decreased ADLs, impaired cognition, and

orthostatic hypotension

Bottom Line:

Patients with gait abnormalities or Hx of falls in the past year are at increased likelihood of falling in the future.

Alcohol AbuseDoes this patient have an alcohol problem?

James M. Kitchens, JAMA. 272(22):1782-7, 1994 Dec 14.

Cage Questionnaire1. Have you ever felt you needed to Cut down on your drinking?2. Have people Annoyed you by criticizing your drinking?3. Have you ever felt Guilty about drinking?4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of

a hangover?

Clinical Results:

Ruling in EtOH abuse

Scores of 3 or 4 have very high likelihood of alcoholism

Ruling out EtOH abuse

Score of 0 has a very high predictive value for ruling out alcoholism.

Evidence:

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Additional Evaluation

Breast CancerDoes this patient have breast cancer? The screening clinical breast examination: should it be done?

Mary B. Barton, Russell Harris, Suzanne W. Fletcher JAMA. 282(13):1270-80, 1999 Oct 6.

Bottom Line:Increased probability of Breast Ca

-The following positive findings on clinical breast examination increase the likelihood of breast cancer: fixed

mass, hard mass, irregular mass and mass size >2cm.

-A well-conducted clinical breast exam can detect up to 50% of asymptomatic breast cancers, and a positive

exam can significantly increase the probability of breast cancer (+LR 10.6)

Decreased Probability of Breast Ca-Negative CBEs should be viewed with caution and additional screening modalities should be utilized in ruling

out breast cancer.

Table 1: Accuracy of various CBE physical findings:

CBE Finding Positive LR

Mass 2.1Fixed 2.4

Hard 1.6

Irregular 1.8

>2cm Lump 1.9

Table 2: Accuracy of the CBE to diagnose breast cancer

Positive LR Negative LR Sensitivity % Specificity %

Pooled Results 10.6 (5.8-19.2) 0.47 (0.40-0.56) 54.1 94

Thyroid GoiterDoes this patient have a Goiter?

Kerry Siminoski. JAMA. 273(10):813-7, 1995 Mar 8

Physical Exam:

-normal thyroid is 2x normal (>40g) is extremely predictive of a goiter being present

(+LR 25)

-Inspection of lateral prominence >2mm is highly predictive of a goiter being present

Decreased Probability of Goiter

-Gland that is not visible with extension of neck virtually rules out a goiter (+LR 0)

Accuracy of Assessing Thyroid Gland Weight Accuracy of Lateral Prominence in assessing Goiter

Thyroid Size Positive LR

Normal, 0-20g 0.15 (0.10-0.21)

1-2x Normal 20-40g 1.9 (1.1-3)

>2x Normal >40g 25 (3.6-175)

Size (Lateral Prominence) Positive LR

not visible 0.41 (0.34-0.49)

0-2mm 3.4 (1.8-6.3)

2-10mm Infinity

>10mm Infinity

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ClubbingDoes This Patient Have Clubbing?

Kathryn A. Myers; Donald R. E. Farquhar. JAMA, Jul 2001; 286: 341 - 347.

Definition:

Clubbing- proliferation of connective tissue between the nail matrix and distal phalanx that results in

symmetrical or asymmetrical enlargement of fingers and/or toes +/- associated with hypertrophic

osteoarthropathy

Physical Exam:

Schamroth Sign- loss of the diamond window that is normally produced when the dorsal surfaces of terminal

phalanges are opposed

Profile sign and Hyponychial angle (See Below)

Phalangeal Depth Ratio- ratio of the distal phalangeal finger depth/ interphalangeal finger depth. Normal < 1.

DPD = distal phalangeal depth, IPD = interphalangeal depth.(Green et al . Introduction to Clinical Medicine. B.C. Decker Inc. Philadelphia)

Clinical Results:

-Profile angle (> 176), hyponychial angle (>192), and phalangeal depth ratio (>1.0 or >1.05 in COPD

patients) suggest the presence of clubbing

-No objective diagnostic criterion has been created to assess clubbing.

-Schamroth sign has not been formally evaluated.

-Interobserver agreement about the presence of clubbing is only fair to moderate

Bottom Line:

In the absence of strong evidence based definition of clubbing and the poor precision of the diagnosis, the above

mentioned methods and values can be used to aid in the diagnosis. If the diagnosis is made, no established

optimal strategy of investigation exists, so the clinician must decide on the best course of investigation.

MelanomaDoes this patient have a mole or a melanoma?

John D. Whited, James M. Crichnik JAMA. 279(9):696-701, 1998 Mar 4.

Physical exam:

ABCD(E) criteria: Asymmetry, Border irregularity, Color irregularity, Diameter >6mm, Elevation

Clinical Results:

Decreased probability of melanoma

-absence of all ABCD criteria virtually ruled out melanoma (-LR 0, Sens 92-100)

Increased probability of melanoma

-presence of border irregularity, color irregularity and diameter >6mm in combination was extremely predictive

of melanoma (+LR 62, spec 98.4)

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Evidence:

Patient HistoryDoes This Patient Have a Family History of Cancer?: An Evidence-Based Analysis of the Accuracy of Family Cancer History

Harvey J. Murff; David R. Spigel; Sapna Syngal. JAMA, September 22/29, 2004; 292: 1480 - 1489.

Clinical Results:

Findings that Increase the Likelihood of a Family Cancer History (+LR):

-Pts with Cancer that report a family history of one of the five types of cancer shown below are likely to be

accurate, however, Prostate and Endometrial Ca have wide Confidence Intervals that are below 5.

-Pts without a history of cancer that report a family history of the five types of cancer shown below are also

likely to be accurate although the +LRs are reduced from Pts with Ca.

Findings that Decrease the Likelihood of a Family Cancer History (-LR):-Pts with Cancer that deny Colon Ca (0.29), Prostate Ca (0.25), Breast Ca (0.07), and Ovarian (0.21) are

accurate.

-Pts without a history of Ca have less accuracy in knowing the absence of Ca in first-

degree relatives compared to Pts with Cancer with Breast being the most accurate

(0.20)

Bottom Line:

Positive family histories for Ca in first-degree relatives are overall accurate, but

negative family histories are not as reliable. Patients with Ca tend to be more accurate.

FHx of Colon and breast Ca are the most reliable.

Evidence:Table 1. Patient Report of a Family History of Cancer in a Table 2. Patient Report of a Family History of Cancer in a

First-Degree Relative in Individuals With Cancer First-Degree Relative in Individuals Without Cancer

Cancer Type Positive LR(95% CI)

Negative LR(95% CI)

Colon 23.0 (8.1-64.0) 0.29 (0.13-0.67)

Prostate 24.0 (2.3-262.0) 0.25 (0.16-0.39)

Breast 41 (23-75) 0.07 (0.03-0.13)

Endometrial 20.0 (4.3-89.0) 0.55 (0.35-0.86)

Ovarian 44 (15-132) 0.21 (0.12-0.37)

Cancer Type Positive LR

(95% CI)

Negative LR

(95% CI)

Colon 23.0 (6.4-81.0) 0.25 (0.10-0.63)

Prostate 12.3 (6.5-24.0) 0.32 (0.18-0.55)

Breast 8.9 (5.4-15.0) 0.20 (0.08-0.49)

Endometrial 14.0 (2.2-83.4) 0.68 (0.31-1.52)

Ovarian 34.0 (5.7-202.0) 0.51 (0.13-2.10)

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Penicillin AllergyIs This Patient Allergic to Penicillin?: An Evidence-Based Analysis of the Likelihood of Penicillin Allergy

Alan R. Salkind; Paul G. Cuddy; John W. Foxworth. JAMA, May 2001; 285: 2498 - 2505.

Clinical Results:

Only 10-20% of Patients that report a penicillin allergy have a true Type I allergic reaction to penicillin.

The +LR of a patient that claims an allergy is 1.9.

The LR of a patient that claims an allergy is 0.5.

Bottom Line:

With the majority of patients making incorrect assumptions to what is a true allergy, a detailed history (ie

Type 1 signs/symptoms of Anaphylaxis and/or hypotension, laryngeal edema, wheezing, angioedema, urticaria

within a short time of consuming the drug) can allow physicians to exclude the allergy. A skin test should be

done if there is a concern and the Abx is required.