Physical exam

What is the utility of bedside skin-fold test in diagnosing Cushing’s syndrome?

FA Manian MD, MPH, , , , , Leave a comment

Skin atrophy is a common feature of Cushing’s syndrome (CS), a hypercortisol state,  with multiple studies reporting radiographic evidence of reduced skin thickness in this condition1,2.

Measurement of skin thickness on the dorsal aspect of the 2nd or 3rd proximal phalanges on the non-dominant hand by using ECG calipers to pinch together a fold of skin has also been reported to assess skin atrophy in CS, with thickness less than 18 mm correlating strongly with CS3,4; the minimal subcutaneous fat at this location allows for a more accurate measurement of skin thickness.

However, caution should be exercised in interpreting the results of this study. Specifically, some overlap was observed between normal controls and patients with CS.  In addition, the study population was limited to women of reproductive age presenting with oligomenorrhea and hirsutism for at least 2 years, a subset of patients that may account for only 40% of cases with CS5,6.  Further studies are clearly needed to determine the clinical utility of the skin-fold test in patients suspected of CS.

References

  1. Sheppard RH, Meema HE. Skin thickness in endocrine disease. A roentgenographic study. Ann Intern Med 1967;66:531-9.
  2. Ferguson JK, Donald RA, Weston TS, et al. Skin thickness in patients with acromegaly and Cushing’s syndrome and response to treatment. Clin Endocrinol (Oxf) 1983;18:347-53.
  3. Corenblum B, Kwan T, Gee S, et al. Bedside assessment of skin-fold thickness: A useful measurement for distinguishing Cushing’s disease from other causes of hirsutism and oligomenorrhea. Arch Intern Med. 1994;154:777-781.
  4. Loriaux DL. Diagnosis and differential diagnosis of Cushing’s syndrome. N Engl J Med 2017;376:1451-9.
  5. Lindholm J, Juul S, Jorgensen JOL, et al: Incidence and late prognosis of Cushing’s syndrome: a population-based study. J Clin Endocrinol Metab 2001;86:117–123.
  6. Lado-Abeal J, Rodriguez-Arnao J, Newell-Price JD, et al. Menstrual abnormalities in women with Cushing’s disease are correlated with hypercortisolemia rather than raised circulating androgen levels. J Clin Endocrinol Metab. 1998;83:3083-8.

Contributed by Sagar Raju, Medical Student, Harvard Medical School

What is the utility of bedside skin-fold test in diagnosing Cushing’s syndrome?

“In my patient with abdominal pain, what physical exam finding can help differentiate abdominal wall from intra-abdominal sources of pain?”

FA Manian MD, MPH, , , , , , 1 Comment

Carnett’s sign (described by a surgeon, J.B. Carnett, in 1926) is a physical exam finding that helps differentiate abdominal wall or psychogenic pain from intra-abdominal sources of pain.

The test is considered positive when, upon locating the tender abdominal spot, the patient’s pain worsens on tensing of the abdominal wall muscles by lifting the head and shoulders from the bed or by raising both legs with straight knees. Conversely, if the pain decreases with this maneuver, an intra-abdominal source is more likely1,2. Sensitivity of ~80%, specificity of ~90%, positive likelihood ratio of 2.6 and negative likelihood ratio of 0.2 have been reported in various studies. 3,4,5

A positive Carnett’s sign should broaden the differential of abdominal pain to include: hernias, irritation of intercostal nerve roots, rectus sheath hematomas, myofascial pain, anterior cutaneous nerve entrapment or ACNES (see related pearl at www.Pearls4Peers.com 6) and psychogenic pain. In the appropriate clinical setting,  local corticosteroids or anesthetic injections, or the application of hot or cold packs may be therapeutic. 2,7

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  References

  1. Carnett JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. J Surg Gynecol Obstet 1926; 42:625-632.
  2. Bundrick JB, Litin SC. Clinical pearls in general internal medicine.  Mayo Clin Proceedings 2011;86: 70–74.  https://mayoclinic.pure.elsevier.com/en/publications/clinical-pearls-in-general-internal-medicine-2.
  3. Takada T, Ikusaka M, Ohira Y, et al. Diagnostic usefulness of Carnett’s test in psychogenic abdominal pain. Intern Med 2011;50:213-17. https://www.jstage.jst.go.jp/article/internalmedicine/50/3/50_3_213/_article
  4. Kamboj Ak, Hoverten P, Oxentenko AS. Chronic abdominal wall pain: a common yet overlooked etiology of chronic abdominal pain. Mayo Clin Proc 2019;94:139-44. https://www.mayoclinicproceedings.org/article/S0025-6196(18)30852-8/pdf
  5. Sweetser S. Abdominal wall pain: a common clinical problem. Mayo Clin Proc 2019;94:347-335.https://www.mayoclinicproceedings.org/article/S0025-6196(18)30671-2/fulltext  
  6. https://pearls4peers.com/2015/11/18/whats-acnes-anterior-cutaneous-nerve-entrapment-syndrome/
  7. Suleiman S , Johnston DE.  The abdominal wall: an overlooked source of pain. Am Fam Physician 2001; 64: 431-8. https://www.ncbi.nlm.nih.gov/pubmed/11515832

Contributed in part by Brad Lander MD, Mass General Hospital, Boston, MA.

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

 

“In my patient with abdominal pain, what physical exam finding can help differentiate abdominal wall from intra-abdominal sources of pain?”

Does electroconvulsive therapy (ECT) pose a risk of embolic stroke in patients with atrial fibrillation (AF)?

FA Manian MD, MPH, , , , , , Leave a comment

Acute embolic stroke in the setting of AF without anticoagulation after ECT has been reported in a single case report in the absence of conversion to normal sinus rhythm (1). Several cases of episodic or persistent conversion to normal sinus rhythm (NSR) in patients with AF undergoing ECT have also been reported (in the absence of embolic stroke), leading some to recommend anticoagulation therapy in such patients (2), though no firm data exist.

The mechanism by which ECT promotes cardioversion from AF to NSR is unclear as direct electrical influence of ECT on the heart is thought to be negligible (1). Arrhythmias such as atrial flutter and AF have also been reported after ECT (1). Curiously, ECT is associated with increased 5- hydroxytryptamine (5- HT2)-receptor densities of platelets in patients with depression which may enhance platelet reactivity and increase the risk of embolic stroke (3) even in the absence of cardioversion.

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References

  1. Suzuki H, Takano T, Tominaga M, et al. Acute embolic stroke in a patient with atrial fibrillation after electroconvulsive therapy. J Cardiol Cases 2010; e12-e14. https://www.sciencedirect.com/science/article/pii/S1878540910000113
  2. Petrides G, Fink M. Atrial fibrillation, anticoagulation, electroconvulsive therapy. Convulsive Therapy 1996;12:91-98. https://journals.lww.com/ectjournal/Abstract/1996/06000/Atrial_Fibrillation,_Anticoagulation,_and.4.aspx
  3. Stain-Malmgren R, Tham A, Ǻberg-Wistedt A. Increased platelet 5-HT2 receptor binding after electroconvulsive therapy in depression. J ECT 1998;14:15-24. https://europepmc.org/abstract/med/9661089
Does electroconvulsive therapy (ECT) pose a risk of embolic stroke in patients with atrial fibrillation (AF)?

Which motor test may be the most useful maneuver when examining a patient suspected of having a stroke?

FA Manian MD, MPH, , , , , Leave a comment

When limited by the number of motor tests that can be performed on a patient suspected of having a stroke, the pronator drift may be your best bet! The sensitivity of this test has varied from 22% to as high as 94% for patients within a week of having a stroke; it is highly specific, however (1,2).

 An advantage of this maneuver is that it can point to subtle lesions in the corticospinal tract (CST) often missed by formal strength testing.

To perform the test, ask the patient to hold his or her arms straight out in front with palms facing upwards and eyes closed for 20-30 seconds. Slight pronation of one hand and flexion of the elbow suggests mild drift. Additional downward drift of the entire arm may also be present with more severe deficits (3). Interestingly, if one arm drifts upward this suggests a lesions outside the CST, possibly a cerebellar or parietal lesion, which may be equally concerning.

 

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References

  1. Louis ED, King D, Sacco R, et al. Upper motor neuron signs in acute stroke: prevalence, interobserver reliability, and timing of initial examination. J Stroke Cerebrovasc Dis 1995;5:49-55. https://www.ncbi.nlm.nih.gov/pubmed/26486559 
  2. Anderson NE, Mason DF, Fink JN. Detection of focal cerebral hemisphere lesions using the neurological examination. J Neurol Neurosurg Psychiatry 2005;76:545-49. https://jnnp.bmj.com/content/jnnp/76/4/545.full.pdf 
  3. Campbell, WW. In DeJong’s The Neurologic Examination-6th Ed, p389-392, 2005. Lippincott Williams&Wilkins, Philadelphia.

 

Contributed in part by Alexis Roy, Harvard Medical Student, Boston, MA.

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Which motor test may be the most useful maneuver when examining a patient suspected of having a stroke?

What is the clinical utility of neck stiffness, Kernig’s sign and Brudzinski’s sign in the evaluation of patients suspected of having meningitis?

FA Manian MD, MPH, , , Leave a comment

The sensitivity of these signs for meningitis is poor: neck stiffness 30% and Kernig’s and Brudzinski’s signs 5% each (1).  Therefore, their absence does not exclude the possibility of meningitis. Although their specificities may be comparatively better (neck stiffness 68%, and Kernig’s and Brudzinski’s signs 95% each), the positive and negative predictive values of these signs generally leave a lot to be desired and their likelihood ratios (both positive and negative) are poor (near 1.0) (1).  

The poor sensitivities of Kernig’s and Brudzinski’s signs may be related to the fact that the original research papers published over 100 years ago involved primarily children with severe bacterial or tuberculous meningitis, a population that is quite different than today’s elderly or immunocompromised patients (2) who may present earlier during their course of disease. Thus, the decision to perform a lumbar puncture should be based primarily on factors other than these signs.

 References

  1. Thomas KE, Hasbun R, Jekel J, et al. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. Clin Infec Dis 2002;35:46-52. https://www.ncbi.nlm.nih.gov/pubmed/12060874 
  2. Mehndiratta M, Nayak R, Garg H, et al. Appraisal of Kernig’s and Brudzinski’s sign in meningitis. Ann Indian Acad Neurol. 2012 Oct-Dec; 15(4): 287–288. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3548367 
What is the clinical utility of neck stiffness, Kernig’s sign and Brudzinski’s sign in the evaluation of patients suspected of having meningitis?

What is the utility of pulmonary auscultation for crackles (rales) in diagnosing congestive heart failure (CHF) or pneumonia?

FA Manian MD, MPH, , , , , , 1 Comment

The evidence for the accuracy of crackles in CHF is not as robust as often assumed, with wide variations in its sensitivity (13%-70%), specificity (35%-100%), positive predictive value (19%-100%), and negative predictive value (17%-85%) (1).

In a study  of patients at high risk for CHF but without valvular heart disease, symptoms of CHF, or comorbid pulmonary disease,  the prevalence of baseline crackles in one or both lungs increased with age: 45-64 y , 11%; 65-79 y, 34%; and 80-95 y, 70%.  At best, fair or poor positive and negative likelihood ratios (LRs) have been reported for crackles in CHF (3.4, and 0.8, respectively) (2). 

The accuracy of crackles in diagnosing pneumonia in patients with cough and fever is not much better: sensitivity 19-67%, specificity 36-94%, and poor positive and negative LRs (1.8 and 0.8, respectively) (2).

So don’t overestimate the accuracy of crackles in CHF or pneumonia, especially if your suspicion for these conditions is high!

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References

  1. Kataoka H, Matsuno O. Age-related pulmonary crackles (rales) in asymptomatic cardiovascular patients. Ann Fam Med 2008;6:239-245.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2384982/ 
  2. McGee S. Auscultation of the lungs. In Evidence-based physical diagnosis (3rd ed.). Elsevier Saunders, Philadelphia, 2012.
What is the utility of pulmonary auscultation for crackles (rales) in diagnosing congestive heart failure (CHF) or pneumonia?

What is the significance of the diagonal ear lobe crease or “Frank’s sign”?

FA Manian MD, MPH, , , , , Leave a comment

Frank’s sign, also known as diagonal earlobe crease (DELC), has often been considered a sign of coronary artery disease (CAD), originally described in patients 60 years of age or younger in 1973 (1). Since then, the majority of clinical, angiographic, and postmortem reports seem to support the association of this physical finding (see figure) with atherosclerotic coronary disease (2,3). In addition, it may be associated with peripheral vascular disease (4) as well as cerebrovascular disease (5).

In a study of hospitalized patients, there was a significant association between DELC and cardiovascular events with a sensitivity of 43% and specificity of 70% (3).

Although the mechanism for this association is unclear, microvascular disease involving the middle ear lobe end-artery territory has been implicated (6).  Free radical oxidative stress activation of the metalloproteinases that break down type 1 collagen has also been suggested (7).

It is fair to conclude, however, that the value of this sign as a screening tool for CAD has not been firmly established and its utility in clinical practice remains uncertain, particularly in those older than 60 years of age or those with diabetes (6).

franks2

 

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 References

1. Frank ST. Aural sign of coronary-artery disease. N Engl J Med 1973;289:327-8. https://www.ncbi.nlm.nih.gov/pubmed/4718047

2. Friedlander AH, Lopez-Lopez J, Velasco-Ortega E. Diagonal ear lobe crease and atherosclerosis: a review of the medical literature and dental implications. Med Oral Patol Oral Cir Bucal 2012;1:e153-9. http://www.medicinaoral.com/pubmed/medoralv17_i1_p153.pdf 

3. Rodriguez-Lopez C. Garlito-Diaz H, Madronero-Mariscal R, et al. Earlobe crease shapes and cardiovascular events. Am J Cardiol 2015;116:286-93. https://www.sciencedirect.com/science/article/abs/pii/S0002914915011200?via%3Dihub

4. Korkmaz L, Agac MT, Acar Z, et al. Earlobe crease may provide predictive information on asymptomatic peripheral arterial disease in patients clinically ree of atherosclertotic vascular disase. Angiology  2014;65:303-7. https://reference.medscape.com/medline/abstract/23449604

5. Celik S, Erdogan T, Gedikli O, et al. Earlobe crease is associated with carotid intima-media thickness in subjects free of clinical cardiovascular disease. Atherosclerosis 2007;192:428-31. https://www.sciencedirect.com/science/article/abs/pii/S0021915006005284

6. Shoenfeld Y, Mor R, Weinberger A, et al. Diagonal earl lobe crease and coronary risk factors. J Am Geriatr Soc 1980;28:184-7. https://www.ncbi.nlm.nih.gov/pubmed/7365179/

7.  Fabijanic D, Culic V. Diagonal ear lobe crease and coronary artery disease. Am J Cardiol 2012;110:1385-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4697048/ 

Contributed in part by Kathryn Dinh, Medical Student, Harvard Medical School, Boston, MA.

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you

 

What is the significance of the diagonal ear lobe crease or “Frank’s sign”?