The neurologic examination

The essentials of the neurological examination are reviewed from the perspective of the emergency medicine practitioner. Important historical information to be obtained, as well as indications and techniques for individual components of the physical examination, are covered. Appropriate and concise methods for documenting the results of the neurological examination in the patient record are also discussed.     

Clinical evaluation and psychological aspects of temporomandibular joint disorders]

Establishing the patient's clinical diagnosis depends on gathering as much information of the patient and his or her signs and symptoms as possible. This information can be gathered from history, physical and psychological examination, diagnostic analysis. It is also important to look upon pain as a disorder and to consider the relationship between pain and psychological factors. The differential diagnosis is constructed through a biopsychological model of illness rather than through a more traditional biomedical model of disease. To arrive at a consistently accurate clinical diagnosis in patients with TMJ and craniofacial pain, the technique of clinical diagnosis must be well defined, reliable and include examination of the head and the neck, cranial nerves and the stomatognathic system. The craniomandibular index provides a standardized examination of the stomatognathic system that has been tested on validity and reliability. This chapter focuses on the techniques of history taking clinical and psychological examination and diagnostic criteria for temporomandibular joint disorders and muscle pain.     

Management of the rape victim

A woman's response to rape can be divided into three phases: an acute reaction, an intermediate stage and a period of resolution. Proper management of the physical and emotional problems of each phase, ideally by the woman's family doctor or gynecologist, may prevent future problems. Treatment during the first phase includes responding to the emotional needs of the patient as well as doing a pelvic and general physical examination to detect any injuries; information for possible legal procedures may be obtained quickly and efficiently. Follow-up particularly psychological, is important in the second and third phases.     

Differential diagnosis in patients with disorders of the patellofemoral joint

Anterior knee complaints are difficult diagnostic problems. It cannot be overstated that the most important information available is to be found in the patient's history. Onset, quality, and quantity of symptoms must be assessed. This information is then synthesized to determine the specific functional disabilities resulting from the patient's anterior knee disorder. Once a history is obtained, a consistent, methodical physical examination can be performed to narrow the differential diagnosis. Radiographic evaluation is used to further hone the differential or to confirm the most likely diagnosis. Ultimately, a specific working diagnosis is selected and treatment is tailored to changing the underlying structural or biomechanical abnormalities that led to the patient's complaints.     

The evaluation and initial management of arthritis

This article reviews the appropriate workup of the patient presenting with complaints referable to a joint, including the important information to be obtained during the interview and physical examination, as well as from laboratory and imaging studies. The clinical presentation of osteoarthritis, rheumatoid arthritis, gout, and joint sepsis are discussed, and the treatment approach for each is outlined. The specific indications for surgical intervention in the course of arthritis also are detailed.     

Can noninvasive diagnostic tools predict tubal rupture or active bleeding in patients with tubal pregnancy?

OBJECTIVE: To determine whether physical examination is useful for patients with suspected ectopic pregnancy (EP) for whom transvaginal sonography is performed and serum hCG levels are measured. DESIGN: Prospective study. SETTING: Two large teaching hospitals. PATIENT(S): Three hundred eighty-two patients with suspected EP, based on a positive urine pregnancy test and the presence of abdominal pain, vaginal bleeding, or risk indicators. INTERVENTION(S): Abdominal examination, speculum inspection, and digital vaginal examination. MAIN OUTCOME MEASURE: A final diagnosis made by transvaginal sonography, serum hCG measurement, and, if necessary, confirmatory laparoscopy. RESULT(S): One hundred sixteen (30%) of the 382 patients had an EP. At external abdominal examination, rebound tenderness and muscular rigidity had likelihood ratios of 3.7 and 8.0, respectively. Findings at speculum inspection and digital vaginal examination had likelihood ratios between 0.33 and 2.4. Logistic regression analysis showed that the additional information provided by physical examination for the diagnosis of EP is limited compared with the information provided by transvaginal sonography and serum hCG measurement alone. CONCLUSION: On the basis of our results, we believe that vaginal digital examination for patients with suspected EP is unnecessary.     

The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study

Between 1 January 1993 and 1 January 1994, 204 consecutive patients with possible blunt abdominal injury were analysed retrospectively. All patients underwent a standardized diagnostic approach on admission to the emergency room. Abdominal ultrasound (AUS) was performed in all cases. If there was evidence of intra-abdominal injury on physical examination or AUS, without signs of persistent hypovolaemia after initial assessment, contrast-enhanced computed tomographic scanning (CECT) of the abdomen was carried out without exception. Physical examination was equivocal in 13 and 3 per cent, respectively, of patients with 'isolated' abdominal trauma (N = 23) or with fractures of lower ribs 7-12 as a sole diagnosis (N = 30). In multiple injury patients (N = 95) or those with suspected 'isolated' head injury (N = 56), these figures reached 45 and 84 per cent, respectively. AUS (N = 204) revealed intra-abdominal injury in 20 per cent of patients, and CECT (N = 43) resulted in additional information in 49 per cent. Patients with 'isolated' head injury showed 9 per cent abnormalities on abdominal evaluation versus 32 per cent in multiple injury patients. In lower rib fractures (7-12) in multiple injury patients abdominal injury was diagnosed in 67 per cent of the cases. We conclude that: (1) negative findings following reliable physical examination of patients with 'isolated' head injury show very high values (NPV 100 per cent), but reliable physical examination is very infrequent (16 per cent); (2) NPV in lower rib fractures due to low energy impact is very high (100 per cent), with a reliable physical examination in most patients (97 per cent); (3) in patients with isolated abdominal trauma 87 per cent have a reliable physical examination with a moderately high NPV (71 per cent); (4) almost half the multiple injury patients have an unequivocal physical examination (45 per cent), with a high NPV following reliable physical examination for abdominal injury (85 per cent); (5) abdominal ultrasonography should be the first step in the radiological assessment of all patients with possible blunt abdominal injury; (6) in multiply injured patients with fractures of their lower ribs (7-12) due to high energy impact the incidence of abdominal injury is very high and CECT might be indicated even in the case of normal AUS findings.     

Childhood sexual abuse reported by facilitated communication

Facilitated communication remains an unproven and controversial strategy for nonspeaking children with developmental disabilities. It is possible that the process may be influenced by the facilitator. The evaluation of alleged sexual abuse reported by FC must include a full psychosocial history, complete physical examination for evidence of abuse, and the assessment of the child's communicative competence. The demonstration of communicative competence requires a strategy similar to that utilized with Carla. The successful documentation of the child's communication of general information should precede the pursuit of specific abuse issues.     

Clinical usefulness of measuring prothrombin time as a routine admission test

A questionnaire indicating the presence of a history or physical findings consistent with liver desease or bleeding disorders was completed by house officers on 301 admissions to a Veterans Administration medical service. Each patient had prothrombin time determined on admission. Only two of 107 patients for whom the prothrombin time was measured as a screening test had an abnormal results and one of these was normal when repeated. Of 73 patients with a history of alcoholism but no other pertient case history or physical examination results, only one had an abnormal prothrombin time. Of the remaining 121 patients, who had a pertinent history or physical examination, 41 had an abnormal admission prothrombin time. We conclude that measurement of prothrombin time adds little additional information to that obtained by history and physical examination in screening for liver disease and coagulation defects unless the patient has specific clinical evidence of liver disease, anticoagulation, or other conditions predisposing to bleeding disorders.     

Follow-up skeletal surveys in suspected child abuse

OBJECTIVE: The purpose of this study was to assess the additional yield of a repeat skeletal survey in identifying and dating skeletal injury for cases in which child abuse was strongly suspected. MATERIALS AND METHODS: Twenty-three infants and toddlers strongly suspected of being physically abused on the basis of findings on the initial skeletal survey, other imaging studies, history, or physical examination underwent a follow-up examination approximately 2 weeks after the initial examination. The high-detail imaging system included a single-emulsion, single-screen combination with a low-absorption carbon-fiber cassette. The skeletal survey protocol entailed tightly collimated anteroposterior views of the appendicular skeleton and anteroposterior and lateral views of the axial skeleton. Between the two studies, all children were in Department of Social Services custody or living in a safe home. RESULTS: The follow-up skeletal survey yielded additional information regarding skeletal injury in 14 (61%) of 23 cases. Follow-up study increased the number of definite fractures detected from 70 to 89 (27%) (p = .005). Most of these additional injuries were classic metaphyseal lesions or rib fractures. In 13 of the 70 fractures previously detected, the follow-up skeletal survey also provided important information about the age of those injuries. CONCLUSION: When child abuse is strongly suspected on the basis of the findings on the initial skeletal survey, other imaging studies, history, or physical examination, a follow-up skeletal survey is recommended to provide a through and accurate assessment of osseous injuries.     

The teaching of physical examination in undergraduate nursing schools in the city of Sao Paulo]

The present study is an exploratory survey attempting to get the point of view of the faculty of subjects considered responsible by teaching physical examination in the nursing undergraduate schools of S?o Paulo city that were selected for this study. The goals were: to detect the situation of teaching of propaedeutics basis; to identify factors that make them difficult; and to identify the recommendations of the faculty for the improvement of teaching and its implementation. The population studied was formed by 39 faculty of the subjects considered responsible by teaching physical examination. Results show us there is not a specific subject to teach physical examination, although it is taught mainly in Fundamental Nursing; faculty are not entirely prepared to teach physical examination. To improve teaching of physical examination, the faculty suggest enhancing their knowledge and skills as well as to create a specific subject to teach physical examination with sufficient hours according to the content.     

Intra-uterine growth retardation

In the primary care setting, asthma and chronic obstructive pulmonary disease are common clinical challenges, which together affect approximately 25,000,000 Americans. As our therapeutic strategies for these two diseases diverge, it becomes important to distinguish between them. Although this may be relatively easy at the extremes of age using a combination of history and physical examination, this review focuses on additional information that may allow diagnostic distinctions to be made in the troublesome middle ground.     

Physical functional level and chronic back pain. Methods for an objective assessment as a part of diagnosis and treatment

Low back pain is a benign situation which affects 50 to 80% of all people in the course of their lives. Usually it heals within some weeks. The few who do not get better within some months are in serious danger of ending up in a human, social and medical impasse. In this respect, ordinary clinical examination methods are of limited value. Functional examination is a very important tool both clinically and from the aspect of health insurance. Work physiological function measurements give possibilities of comparing the information on patients with normative data. They also establish a basis for quality control after treatment. The purpose of this article is to describe measurement methods to assess the level of physical function of persons with chronic back pain. The criteria for choosing the methods of examination are also discussed.     

Herniography in symptomatic patients following inguinal hernia repair

Patients with symptoms at the site of a previous inguinal hernia repair may constitute a diagnostic dilemma. The usefulness of herniography in the assessment of these patients was evaluated at 54 symptomatic sites in 46 subjects. Ten persistent or recurrent hernias were shown by herniography, only 2 of which were definitely detected on physical examination. The herniogram was normal at 44 sites, of which, on physical examination, 5 were equivocal and 1 was diagnosed as a definite hernia. On the unoperated-on or asymptomatic side, a total of 14 hernias were shown herniographically. Of these hernias, 8 were not detected on physical examination. Herniography was found to be more sensitive than physical examination in detecting hernias at the symptomatic, previously operated-on sites, as well as at the unoperated-on or asymptomatic sites. When a herniogram provides corroborative evidence that hernia has not recurred, the need for reexploration may be eliminated.     

Role of axillary lymph node dissection after tumor downstaging with induction chemotherapy for locally advanced breast cancer

BACKGROUND: Induction chemotherapy has become the standard of care for patients with locally advanced breast cancer (LABC) and currently is being evaluated in prospective clinical trials in patients with earlier-stage disease. To better gauge the role of axillary lymph node dissection in patients with LABC this study was performed to assess initial axillary status on physical and ultrasound examination, axillary tumor downstaging following induction chemotherapy, and the accuracy of physical examination compared with axillary sonography in predicting which patients will have axillary lymph node metastases found on pathologic examination. METHODS: Between 1992 and 1996, 147 consecutive patients with LABC were registered in a prospective trial of induction chemotherapy using 5-fluorouracil, doxorubicin, and cyclophosphamide. Physical and ultrasound examinations of the axilla were performed at diagnosis and after induction chemotherapy. Segmental resection with axillary lymph node dissection or modified radical mastectomy was performed, followed by postoperative chemotherapy and irradiation of the breast or chest wall and regional lymphatics. RESULTS: Following induction chemotherapy, 43 (32%) of the 133 patients with clinically positive lymph nodes on initial examination had axillary tumor downstaging as assessed by physical and ultrasound examination. The sensitivity of axillary sonography in identifying axillary metastases was significantly higher than that of physical examination (62% vs. 45%, P=.012). The specificity of physical examination (84%) was higher than that of sonography (70%), but the difference did not reach statistical significance. Among the 55 patients in whom the findings of both physical and ultrasound examination of the axilla were negative following induction chemotherapy, 29 patients (53%) were found to have axillary lymph node metastases on pathologic examination of the axillary contents. However, 28 (97%) of these patients had either 1 to 3 positive lymph nodes or only micrometastases 2 to 5 mm in diameter. CONCLUSIONS: Preoperative clinical assessment of the axilla by physical examination combined with ultrasound examination is not completely accurate in predicting metastases in patients with LABC following tumor downstaging. However, patients with negative findings on both physical and ultrasound examinations of the axilla may be potential candidates for omission of axillary dissection if the axilla will be irradiated because minimal axillary disease remains. Patients who have positive findings on preoperative physical or ultrasound examinations should receive axillary dissection to ensure local control. A prospective randomized trial of axillary dissection versus axillary radiotherapy in patients with a clinically negative axilla following induction chemotherapy is currently underway.     

Changes in physical fitness and changes in mortality

BACKGROUND: Point estimates of physical fitness give important information on the risk of death in healthy people, but there is little information available on effects of sequential changes in physical fitness on mortality. We studied this latter aspect in healthy middle-aged men over a total follow-up period of 22 years. METHODS: 2014 healthy men aged 40-60 years had a bicycle exercise test and clinical examination, and completed a questionnaire in 1972-75 (survey 1). This was repeated for 1756 (91%) of 1932 men still alive by Dec 31, 1982 (survey 2). The exercise scores were adjusted for age. The change in exercise scores between surveys was divided into quartiles (Q1=least fit, Q4=fittest). An adjusted Cox's proportional hazards model was used to study the association between changes in physical fitness and mortality, with the Q1 men used as controls. FINDINGS: By Dec 31, 1994, 238 (17%) of the 1428 men had died, 120 from cardiovascular causes. There were 37 deaths in the Q4 group (19 cardiovascular); their relative risks of death were 0.45 (95% CI 0.29-0.69) for any cause and 0.47 (0.26-0.86) for cardiovascular causes. There was a graded, inverse relation between changes in physical fitness and mortality irrespective of physical fitness status at survey 1. INTERPRETATION: Change in physical fitness in healthy middle-aged men is a strong predictor of mortality. Even small improvements in physical fitness are associated with a significantly lowered risk of death. If confirmed, these findings should be used to influence public health policy.     

Patients' rights in laboratory examinations: do they realize?

This article discusses the rights of patients who are attending hospital for the most common laboratory examinations and who may also be taking part in research studies. A distinction is made between five kinds of rights to: protection of privacy, physical integrity, mental integrity, information and self-determination. The data were collected (n = 204) by means of a structured questionnaire specifically developed for this study in the clinical chemistry, haematological, physiological and neurophysiological laboratories of one randomly selected university hospital in Finland. The analysis of the data was statistical. On the whole, patients' rights were realized reasonably well. This was most particularly the case with protection of privacy, as well as with the rights of physical and mental integrity. The rights to information and self-determination were less well realized. There are various steps that health care professionals and organizations can take to make sure that patients can enjoy their full rights, by counselling the patient, by giving opportunities to plan the examinations in advance, and by arranging a sufficient number of small examination rooms.     

Nursing management of sleep disorders: Part 1--Assessment

Insomnia and hypersomnia are the two most frequent sleep complaints. This article will focus on the assessment of these two symptoms. A thorough assessment, which includes a sleep history, information about the person's habits, a family history, a social history, a health history and a physical examination is necessary to determine the cause of patients' symptoms.     

Poisoning and overdose

The differential diagnosis of all patients with altered mental status must include drug toxicity. In particular, intentional or unintentional overdosing and/or poisoning are common emergency department presenting complaints. A comprehensive approach to managing these patients must incorporate aggressive information gathering, a careful physical examination looking for toxic syndromes, and diagnostic testing. Proper decontamination is the key to effective management, as is the use of specific antidotes when indicated.     

Hydrogen peroxide-enhanced transanal ultrasound in the assessment of fistula-in-ano

Appropriate classification of the fistulous tracts in patients with fistula-in-ano may be of value for the planning of proper surgery. Conventional transanal ultrasound has limited value in the visualization of fistulous tracts and their internal openings. Hydrogen peroxide can be used as a contrast medium for ultrasound to improve visualization of fistulas. PURPOSE: This prospective study evaluates hydrogen peroxide-enhanced ultrasound in comparison with physical examination, standard ultrasound, and surgery in the assessment of fistula-in-ano. METHODS: Twenty-one consecutive patients (4 women; mean age, 42 years) with fistula-in-ano were evaluated by local physical examination (inspection, probing, and digital examination), conventional ultrasound, and hydrogen peroxide-enhanced ultrasound before surgery. Ultrasound was performed using a B&K Diagnostic Ultrasound System with a 7-MHz rotating endoprobe. Hydrogen peroxide (3%) was infused via a small catheter into the fistula. The results of physical examination, ultrasound, and hydrogen peroxide-enhanced ultrasound were compared with surgical data as the criterion standard. The additive value of standard ultrasound and hydrogen peroxide-enhanced ultrasound compared with physical examination was also determined. RESULTS: At surgery, 8 intersphincteric and 11 transsphincteric fistulas and 2 sinus tracts (without an internal opening) were found. During physical examination, probing was incomplete in 13 patients, the diagnosis being correct in the other 8 patients (38%) as a low (intersphincteric or transsphincteric) fistula. With conventional ultrasound, the assessment of fistula-in-ano was correct in 13 patients (62%); defects in one or both sphincters could also be found (n = 8). With hydrogen peroxide-enhanced ultrasound, the fistulous tract was classified correctly in 20 patients, the overall concordance with surgery being 95%. The internal opening was found at physical examination in 15 patients (71%), with hydrogen peroxide-enhanced ultrasound in 10 patients (48%), and during surgery in 19 patients (90%). Secondary extensions, confirmed during surgery, were found in five cases. In two patients, a secondary extension with hydrogen peroxide-enhanced ultrasound was not confirmed during surgery. Both patients developed a recurrent fistula. CONCLUSION: Hydrogen peroxide-enhanced ultrasound is superior to physical examination and standard ultrasound in delineating the anatomic course of perianal fistulas. It makes accurate preoperative assessment of the fistula possible and may be of value for the surgeon in planning therapeutic strategy.