Ascites

At Gel Rounds we discussed ascites.

Some key points:

Most sensitive findings (i.e. make it unlikely if not present):
1) flank dullness
2) bulging flanks
3) shifting dullness
4) peripheral edema
-history of increased girth, weight gain, ankle swelling

Most specific findings (i.e. make it likely if present)
1) fluid wave
2) shifting dullness

An approach to the examination in liver disease (besides examining the liver itself)

1) Signs of decompensated liver disease
-jaundice, scleral icterus, dark urine (high bilirubin)
-petechiae, ecchymoses (coagulopathy)
-edema (hypoalbuminemia)
-asterixis, level of consciousness (encephalopathy)

2) Signs of portal hypertension
-ascites
-splenomegaly
-dilated abdominal veins (extreme of this is caput medusae)
-hemorrhoids

Reference:

Click here for JAMA rational clinical exam on ascites.

* using the ultrasound, we looked at the Pouch of Morrison, which is a potential space between the liver and the right kidney. This is the first spot to check if you suspect a small amount of ascites. The picture shows Morison's pouch with fluid present (red arrows).

Is This Patient Malnourished?

In our physical exam rounds today, we examined a patient for signs of malnutrition, and reviewed the JAMA RCE article on the topic.

The gist of the articles is to know the “Subjective Global Assessment” which includes the following:
•History (Weight change,Dietary intake change,GI symptoms,Functional capacity)
•Physical exam (Loss of subcutaneous fat, Muscle wasting, Edema)

Based the above, you can categorize patients into “well-nourished”, “moderately malnourished”, or “severely malnourished”. These categories then correlate with patient likelihood of being admitted, and post-operative complications.

Here is the article.
http://www.ncbi.nlm.nih.gov.myaccess.library.utoronto.ca/pubmed?term=is%20this%20patient%20malnourished%20detsky%20JAMA

* Given our topic of conversation, I like to remind everyone of the famine in East Africa. A devastating drought and crumbling infrastructure have created one of the worst hunger emergencies in our generation. If you would like to make a donation, the Government of Canada has created the East Africa Drought Relief Fund, and will match your donations.

Tricuspid Regurgitation

For sportscar connaisseurs, the iconic Ferrari 512TR

Today we discussed tricuspid regurgitation at physical exam rounds. Some points:

There are generally 2 classes of TR: 1) High pressure, usually secondary to L-heart disease (high RVSP), and 2) low pressure, usually from bacterial endocarditis.

In general, only the high pressure variety is detectable on physical exam because a significant pressure gradient between the RV and RA is required to generate the findings listed below.

The JVP:
-Elevated JVP: Seen in 90% of patients. Its absence strongly argues against high pressure TR
-CV waves: a systolic impulse of the neck veins is seen in about 50-80% of patients. You normally expect to see a descent in the JVP (the X' descent) during early systole (i.e. during and right after S1). If you do not see a descent, the patient probably has a CV wave.

Precordial palpation:
-If the RV is dilated, it may occupy the space where the LV normally lies (i.e. the apex). In this situation, you may see and palpate a systolic retraction of the apex with an outward movement of the L or R lower sternal borders (where the dilated RA lies), which is described as a "rocking" motion

Murmur:
-The murmur of TR is holosystolic. In 75% of patients, it becomes louder with inspiration (called Carvallo's sign). It is usually loudest at the L lower sternal border, but if the RV is dilated enough may be loudest at the apex. The LR+ for a typical murmur is 14.6. However, the lack of a typical murmur does not rule out TR (negative LR 0.8 for mild, 0.4 for severe).

Other:
-Pulsatile liver may be palpated (wide range of sensitivities reported). It is not 100% specific for TR (constrictive pericarditis and hepatic AVMs may also cause it), but by far the most common cause. Its presence argues that the TR is moderate to severe.
-Edema, ascites: 90% of patients have edema or ascites (or both)

Reference:

There is no JAMA RCE specifically for TR; most of above is taken from
Evidence-Based Physical Diagnosis (McKee)

Obstructive lung disease

At physical exam rounds, we discussed the diagnosis of obstructive lung disease.

There are many potential findings, outlined below, and 3 major papers on the evidence-based diagnosis of obstructive lung disease.


Possible findings:

General inspection:
Signs of respiratory distress (accessory muscle use, indrawing, paradoxical abdominal movement), pursed lip breathing, barrel chest, signs of malnutrition, look for clubbing (not expected in COPD), asterixis from CO2 retention, cyanosis, elevated JVP from cor pulmonale, many other possibilities...

Vitals:
Pulsus paradoxus

Palpation:
Subxiphoid cardiac impulse, palpable P2 from pulmonary HTN

Percussion:
Hyperresonance
Decreased diaphragmatic excursion
Decreased cardiac dullness

Auscultation:
Wheezes

Special manouevers:
Forced expiratory time (Patient takes a deep breath and exhales forcefully with open mouth, and examiner listens over lower trachea)
Laryngeal height- measure the maximum distance between the sternal notch and the thyroid cartilage. Less than 4cm is significant.

Evidence:

From JAMA Rational Clinical exam (1995):

Most sensitive tests (i.e. rule out if not present)- no single test sensitive enough
Most specific tests (i.e. rule in if present)
Wheezing (LR 36)
Barrel chest (LR 10)
Decreased cardiac dullness (LR 10)
Match test (patient unable to blow out match held 10cm in front with open mouth) (LR 7.1)
Hyperresonance
Forced exp time over 9 seconds
Other less useful tests to rule in, but positive LR's: Forced exp time 6-9s, subxiphoid impulse, pulsus paradoxus over 15, decreased breath sounds.


From JGIM- Straus et al, 2002
Took 161 pts with varying disease severity (known, suspected, or no COPD), did spirometry on all, looked at components of history and physical that predicted FEV1 5th percentile.

Key point here is combining findings is powerful in ruling in or ruling out.

Forced exp time over 9 seconds - LR 6.7
Wheezing - LR 4.0
Self-reported COPD LR 5.6

If all 3, LR 59 (rules in). If none, LR 0.3 (i.e. good for ruling out)

Other significant features: Over 40 pack-year smoker: LR 3.3


From JAMA- Straus et al (2000)- primary study, not Rational Clinical Exam

History of smoking over 40 pack-years: LR 8.3
Self-reported COPD: LR 7.3
Maximum laryngeal height less than 4cm LR: 2.8
Age over 45 LR 1.3

If all 4, LR is over 200
If none, LR- is 0.13

Links

For JAMA Rational Clinical Exam abstract click here

For Straus et al JAMA paper click here

For Straus et al JGIM paper click here