How well can an expert examiner detect synovitis of the fingers?

Summary:

Even an expert has difficulty and only detected by palpation 25% of finger joints that had swelling by ultrasounds.

Patients:

• The authors examined 165 finger tendons from “33 consecutive patients who has originally presented with polyarthritis and clinical suspicion of inflammatory arthritis of the hands and wrists (symptoms < 24 months)”

Examiner:

• “senior rheumatologist trained in the detection of musculoskeletal disorders (AS), who disregarded ultrasonography findings”

Reference standard:

• Ultrasound

Results:

52% (17 patients) had flexor tenosynovitis by ultrasound.

Performance of the expert clinical examiner.

	Sensitivity (%)	Specificity (%)
Tenderness	87	47
Crepitus	56	76
Swelling	25	100

Citation:

Hmamouchi I, Bahiri R, Srifi N, Aktaou S, Abouqal R, & Hajjaj-Hassouni N (2011). A comparison of ultrasound and clinical examination in the detection of flexor tenosynovitis in early arthritis. BMC musculoskeletal disorders, 12 PMID: 21549008

Signs of cervical spinal cord compression

This is a retrospective, unblinded  study of 120 patients without comorbidities undergoing laminoplasty for cervical myelopathy, defined as increased signal intensity (ISI) in T2-weighted magnetic resonance imaging (MRI).

On physical examination, the most sensitive findings were:

• Hyperreflexia of knee 94%
• Hoffmann reflex (“flexion of the ipsilateral thumb and/or index finger was considered as positive”) 81%
• Babinski sign 53%
• Ankle clonus 35%

These results are likely inflated due to lack of control group which prevented blinding.  In addition, the authors noted that the signs were less sensitive in patients with mild disability. Regardless, I suspect the relative values of the signs are correct and I was surprised on the value of the Hoffmann reflex.

Citation:

Chikuda H, Seichi A, Takeshita K, Shoda N, Ono T, Matsudaira K, Kawaguchi H, & Nakamura K (2010). Correlation between pyramidal signs and the severity of cervical myelopathy. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 19 (10), 1684-9 PMID: 20229121

A “mini” Mini-Mental State Examination

The authors propose a six item screener (SIS) that contains six items from the Mini-Mental State Examination (MMSE):

The examiner first asks the patient to remember three items: GRASS PAPER SHOE. The examiner could repeat the words 3 times as needed to help the patient.

• Orientation to time
1. Year
2. Month
3. Day of the week
• Recall of three items (one point each)

Patients: The authors studied 371 patients in the emergency room after excluding 587 patients, mostly due to having received sedating medications.

Results: As compared to the full MMSE, the accuracy of the SIS was:

• Sensitivity 74%
• Specificity 77%

Citation:

Carpenter CR, Despain B, Keeling TN, Shah M, & Rothenberger M (2011). The Six-Item Screener and AD8 for the Detection of Cognitive Impairment in Geriatric Emergency Department Patients. Annals of emergency medicine, 57 (6), 653-61 PMID: 20855129

Differentiating epileptic seizures and pseuodseizures

In a study of 120 events from 35 consecutive patients referred for video electroencephalography (VEEG) monitoring:

Video-documented predictors of psychogenic nonepileptic seizures were:

• “preserved awareness,” “eye flutter,” and “bystanders can intensify or alleviate”)

Video-documented predictors of epileptic seizures were:

• “abrupt onset,” “eye-opening/widening,” and postictal “confusion/sleep”

However, “eyewitness reports of these 6 signs were inaccurate and not statistically different from guessing.”

Clinical examination for peripheral arterial disease

Summary:

If both pulses on both feet are normal and there are no femoral bruits, there is a less than 10% chance of an ABI being abnormal in a study population with a prevalence of disease of 28%. I could not make any other conclusions from this article.

Methods:

Patients:

1619 patients who has undergone peripheral arterial testing between December 2005 and February 2010. Excluded:

• 228 due to an abnormally high ABI (greater than 1.30) in either leg
• 155 patients because the examination for femoral bruit was not recorded
• 1 patient because the examination for distal pulses was not recorded

Reference standad:

• ABI <= 0.9

Results:

• 1236 patients (2472 legs)
• API was abnormal in at least on leg of 348 patients (28%)
• 575 patients had a normal clinical examination (no femoral bruits and both pulses on both feet normal) and 546 of these (95%) has normal ABIs. I calculate the confidence interval is 92.75 % to 96.54 %.
• The authors state that a complete clinical examination has a sensitivity and specificity of 58.2% and 98.3%; however, I cannot reproduce these numbers. The problem may be due to the authors inconsistently reporting number of patients versus number of legs and also not clearly stating whether an abnormal examination is when any one finding is abnormal or when all findings are abnormal.

Citation

Armstrong DW, Tobin C, & Matangi MF (2010). The accuracy of the physical examination for the detection of lower extremity peripheral arterial disease. The Canadian journal of cardiology, 26 (10) PMID: 21165366

Carnett’s test for excluding intra-abdominal origins of abdominal tenderness

Interpretation of this study is difficult since the authors excluded patients with functional gastrointestinal disorders. I will continue to use Carnett’s sign as one vote among components of the evaluation of abdominal pain.

Methods

Patients and examiners

130 consecutive outpatients with abdominal tenderness. “Patients who had functional
gastrointestinal disorders such as functional dyspepsia or irritable bowel syndrome were excluded from the analysis because of the potential for comorbidity by psychiatric disorders.”

Two of 8 generalist physicians with a mean of 7 years in practice examined each patient. One examiner knew the patient’s medical history and one was blinded.

Description of the test

“After routine examination of the abdomen, the site of maximum
tenderness is determined. The patient is then asked to
contract the abdominal muscles by raising his/her head from
the examination table while the examiner continues to apply
pressure to the tender site. The test is positive if tenderness
becomes more severe or is unchanged. A positive test suggests
that the abdominal wall is the source of pain. On the
other hand, the test is negative when tenderness is reduced,
which suggests that the pain has an intra-abdominal source.”

Reference standard

Final diagnosis after clinical evaluation.

Results

Results are in the Figure. 86% of patients with abdominal wall or psychogenic pain had a positive test. 13% of patients with intra-abdominal causes of pain had a positive test.

The reproducibility was high, κ=0.81.

Citation

Takada T, Ikusaka M, Ohira Y, Noda K, & Tsukamoto T (2011). Diagnostic usefulness of Carnett’s test in psychogenic abdominal pain. Internal medicine (Tokyo, Japan), 50 (3), 213-7 PMID: 21297322

Digiti quinti sign for hemiparesis

Patients: Sixty patients with unilateral brain tumors without obvious focal signs and 30 controls

Examination: A physical therapist, blinded to all clinical and  imaging data, performed 13 clinical tests. A photograph of the digiti quinti sign is at http://pubmed.gov/20799429. In this test, the patient extends arms as for the pronator drift test, but turns palms down. In an abnormal test, the 5th finger on the weak side abducts more than the 5th finger on the normal side.

Outcome: MRI

Results:

Selected results from 13 tests that were studied.

Test	Sensitivity	Specificity
Digiti quinti sign	51% (41-61)	70% (61-79)
Pronator drifting test	41% (31-51)	96% (92-99)
Babinski sign	8%(2-14)	100%

Comment: this study used a case control design and so is subject to spectrum bias. However, restricting all patients to those without obvious focal signs may somewhat compensate.

This has been added to http://en.citizendium.org/wiki/Digiti_quinti_sign

Citation

Maranhão ET, Maranhão-Filho P, Lima MA, & Vincent MB (2010). Can clinical tests detect early signs of monohemispheric brain tumors? Journal of neurologic physical therapy : JNPT, 34 (3), 145-9 PMID: 20799429

Distinguishing categories of shock

Patients: 68 adults with more than  30 minutes of systolic blood pressure <90 mmHg

Examination: performed by medicine house officers.

Outcome: Category of shock classified by a single, blinded, experienced clinician using published consensus guidelines when available.

Results: The combination of estimation of the skin temperature (patient’s hand cooler than the examiner’s hand) and central venous pressure (CVP >7 cm) correctly categorized 52 of 68 cases (accuracy = 76%).

Although not explicitly stated, the categorization seems to be:

• Septic shock (37 patients): warm hands; CVP  < 8 cm.
• Cardiogenic shock (18 patients): cool hands, CVP  > 7 cm.
• Hypovolemic shock (13 patients): cool hands, CVP  < 8 cm.

Comment: The authors used an odd definition of pulse pressure, “same/wider vs. thinner than examiner’s”, which may have prevented this sign from being significant. Other studies have found that a proportional pulse pressure < 25% is predictive of poor cardiac physiology (PMID: 2913385; PMID: 11420761)

This has been added to http://en.citizendium.org/wiki/Shock_(physiology).

Citation

Vazquez R, Gheorghe C, Kaufman D, & Manthous CA (2010). Accuracy of bedside physical examination in distinguishing categories of shock: a pilot study. Journal of hospital medicine : an official publication of the Society of Hospital Medicine, 5 (8), 471-4 PMID: 20945471

Cervical neck rotation for headache diagnosis

Patients: The authors performed a cross sectional study of 60 patients who came from three groups of 20 patients: migraine headache, cervicogenic headache, and mixed headache.  The examiners were not aware of the patients’ diagnoses.

Examination: The cervical flexion–rotation test (FRT) maneuver “consisted of pre-positioning the cervical spine in maximal end range flexion followed by passive rotation of the head to the left and the right, with the subject relaxed in supine. End of range was determined either by firm resistance encountered by the therapist or the subject reporting the onset of pain, whichever came first.” The examination was done on a symptom-free day.

Results: The best cutoff with 30 degrees of rotation; patients with less than 30 degrees were more likely to have cervicogenic headache. The authors found that the area under the receiver operating characteristic curve was 0.85; however, the authors did not provide the sensitivity and specificity for that cutoff value.

Comment: The results of the study may be inflated. It is not clear whether the authors studied consecutive patients with headache or if the study was subject to spectrum bias. In addition, the patients with cervicogenic headache 10 years older which may influence cervical mobility.

Citation:

Hall TM, Briffa K, Hopper D, & Robinson K (2010). Comparative analysis and diagnostic accuracy of the cervical flexion-rotation test. The Journal of Headache and Pain, 11 (5), 391-7 PMID: 20508964

Diagnosing Gout

Clinical Diagnosis of Gout

Patients: In a study of 381 patients recruited by family physicians because of monoarthritis, 57% had positive crystals and one patient had a bacterial infection.

Results: The family physicians had an accuracy of:

• Sensitivity 97%
• Specificity 28%

The authors then created a prediction rule for the 328 patients that the family physicians suspected had gout:

Male sex 2.0 points
Previous patient-reported arthritis attack 2.0 points
Onset within 1 d 0.5 points
Joint redness 1.0 points
MIP involvement  2.5 points
Hypertension or and cardiovascular diseases 1.5 points
Serum uric acid level >5.88 m9/dL  3.5 points

The prediction rule had an accuracy of:

• 8 or more points
  • Sensitivity 92% (193/209)
  • Specificity 88% (77/88)
• 4 or less points
  • Sensitivity 99% (208/209)
  • Specificity 50% (44/88)

If 4 or less points, the NPV is 98%.

If 8 or more points, the PPV=95%.

Comment: Even if using the prediction rule developed in this study, physicians should consider aspirating most all joints with monoarthritis as value even in joints suggestive of gout had a one in 20 chance of an alternative diagnosis. Also, the label of gout may affect future decision making and life-long medications.

References:

1. Janssens HJ, Fransen J, van de Lisdonk EH, van Riel PL, van Weel C, & Janssen M (2010). A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Archives of Internal Medicine, 170 (13), 1120-6 PMID: 20625017

2. Peláez-Ballestas I, Hernández Cuevas C, Burgos-Vargas R, Hernández Roque L, Terán L, Espinoza J et al. (2010) Diagnosis of chronic gout: evaluating the american college of rheumatology proposal, European league against rheumatism recommendations, and clinical judgment. J Rheumatol 37 (8):1743-8. DOI: 10.3899/jrheum.091385 PMID: 20551101.