Invasive Ductal Breast Carcinoma Metastasis to the Uterine Cervix Presenting As Heavy Vaginal Bleeding: A Case Report and a Literature Review.

Breast carcinoma metastasis to the uterine cervix is a rare occurrence with diagnostic intricacies. We present a case of a 38-year-old woman diagnosed with bilateral stages IIIA and IIIB invasive ductal carcinoma of the breast who developed heavy vaginal bleeding post-treatment, revealing metastatic involvement of the cervix, confirmed by CT imaging and pathological examination, as the presenting sign of widely metastatic disease. This case underscores the importance of a thorough review of systems and physical exams as well as considering uncommon metastatic sites in breast cancer patients.

Comparative Analysis of Large Language Models in Emergency Plastic Surgery Decision-Making: The Role of Physical Exam Data.

In the U.S., diagnostic errors are common across various healthcare settings due to factors like complex procedures and multiple healthcare providers, often exacerbated by inadequate initial evaluations. This study explores the role of Large Language Models (LLMs), specifically OpenAI's ChatGPT-4 and Google Gemini, in improving emergency decision-making in plastic and reconstructive surgery by evaluating their effectiveness both with and without physical examination data. Thirty medical vignettes covering emergency conditions such as fractures and nerve injuries were used to assess the diagnostic and management responses of the models. These responses were evaluated by medical professionals against established clinical guidelines, using statistical analyses including the Wilcoxon rank-sum test. Results showed that ChatGPT-4 consistently outperformed Gemini in both diagnosis and management, irrespective of the presence of physical examination data, though no significant differences were noted within each model's performance across different data scenarios. Conclusively, while ChatGPT-4 demonstrates superior accuracy and management capabilities, the addition of physical examination data, though enhancing response detail, did not significantly surpass traditional medical resources. This underscores the utility of AI in supporting clinical decision-making, particularly in scenarios with limited data, suggesting its role as a complement to, rather than a replacement for, comprehensive clinical evaluation and expertise.

Measures of nutrition status and health for weight-inclusive patient care: A narrative review.

In healthcare, weight is often equated to and used as a marker for health. In examining nutrition and health status, there are many more effective markers independent of weight. In this article, we review practical and emerging clinical applications of technologies and tools used to collect non-weight-related data in nutrition assessment, monitoring, and evaluation in the outpatient setting. The aim is to provide clinicians with new ideas about various types of data to evaluate and track in nutrition care.

Impact of COVID-19 pandemic on physical health amongst children: Difference-in-differences analyses of nationwide school health checkup database.

INTRODUCTION: The COVID-19 pandemic posed tremendous challenges for children. However, the long-term effects of the pandemic on various aspects of physical health at a national level remain unclear. METHODS: In this retrospective cohort study, we analysed data from nationwide health checkup records amongst children aged 7-15 years. The dataset comprised 3 544 146 records from 393 794 individuals who graduated from junior high school during fiscal years 2007 to 2022. Difference-in-differences (DID) analyses with multiple time periods were used to examine the impact of COVID-19 on physical health outcomes. RESULTS: Compared with the pre-pandemic period, the COVID-19 pandemic was associated with excess increases in obesity for boys and girls, persisting over the 3 years (+0.42%; [95% CI, 0.23-0.61]). Also, it was associated with excess increases in underweight (+0.28% [0.25-0.32]) and poor visual acuity amongst boys in the 3rd year (+1.80% [1.30-2.30]). There were excess reductions in dental caries (-1.48% [-2.01 to -0.95]), glucosuria (-0.55 [-0.88 to -0.23]) and hematuria (-0.43% [-0.73 to -0.13]) during the 3rd year of the pandemic. CONCLUSIONS: These findings underscore the multifaceted impact of the pandemic on various health indicators for school-aged children. This information could be valuable for public health policy and paediatric healthcare planning in the post-pandemic era.

Performance of Cardiovascular Physical Exam Skills by Internal Medicine Residents.

BACKGROUND: Few studies have assessed the ability of internal medicine residents to perform a cardiovascular physical examination using real patients. METHODS: First year internal medicine interns from 2 large academic medical centers in Maryland examined the same patient with aortic insufficiency as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were assessed on 5 clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs. RESULTS: One hundred nine interns examined the same patient with aortic insufficiency across 14 APECS sessions. Only 58 interns (53.2%) correctly identified the presence of a diastolic murmur, and only 52 interns (47.7%) included aortic insufficiency on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of the correct physical findings (r = 0.42, P < .001). Both technique (r = 0.34, P = .003) and identifying findings (r = 0.42, P < .001) were significantly associated with generating an appropriate differential diagnosis. Common errors in technique included auscultating over the gown, timing the cardiac cycle with the radial pulse, and failing to palpate for the apical impulse. CONCLUSIONS: Internal medicine interns had variable skills in performing and interpreting the cardiovascular physical exam. Improving cardiovascular exam skills would likely lead to increased identification of relevant cardiovascular findings, inform clinical decision making and improve overall patient care.

Establishing the diagnosis of radial tunnel syndrome: a systematic review of published clinical series.

PURPOSE: Radial tunnel syndrome (RTS) is a controversial diagnosis due to non-specific exam findings and frequent absence of positive electromyography (EMG) and nerve conduction study (NCS) findings. The purpose of this study was to identify the methods used to diagnose RTS in the literature. METHODS: We queried PubMed, Embase, Web of Science, and Cochrane databases per PRISMA guidelines. Extracted data included article and patient characteristics, diagnostic assessments utilized and their respective findings, and treatments. Objective data were summarized descriptively. The relationship between reported diagnostic findings (i.e., physical exam and diagnostic tests) and treatments was assessed via a descriptive synthesis. RESULTS: Our review included 13 studies and 391 upper extremities. All studies utilized physical exam in diagnosing RTS; most commonly, patients had tenderness over the radial tunnel (381/391, 97%). Preoperative EMG/NCS was reported by 11/13 studies, with abnormal findings in 8.9% (29/327) of upper extremities. Steroid and/or lidocaine injection for presumed lateral epicondylitis was reported by 9/13 studies (46/295 upper extremities, 16%), with RTS being diagnosed after patients received little to no relief. It was also common to inject the radial tunnel to make the diagnosis (218/295, 74%). The most common reported intraoperative finding was narrowing of the PIN (38/137, 28%). The intraoperative compressive site most commonly reported was the arcade of Frohse (142/306, 46%). CONCLUSIONS: There is substantial heterogeneity in modalities used to diagnose RTS and the reported definition of RTS. This, in conjunction with many patients having concomitant lateral epicondylitis, makes it difficult to compare treatment outcomes for RTS. LEVEL OF EVIDENCE: Level III. Systematic review of retrospective and prospective cohort studies.

Adolescent Idiopathic Scoliosis Minimum Data Set: Towards Standardization of Data Elements in History and Physical Examination.

INTRODUCTION: Nonoperative care represents a cornerstone of adolescent idiopathic scoliosis (AIS) management, although no consensus exists for a minimal data set. We aimed to determine a consensus in critical data points to obtain during clinical AIS visits. METHODS: A REDCap-based survey was distributed to Pediatric Orthopedic Society of America (POSNA), Pediatric Spine Study Group (PSSG), and International Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT). Respondents ranked the importance of data points in history, physical examination, and bracing during AIS visits.  Results: One hundred eighty-one responses were received (26% response rate), of which 86% were physicians and 14% were allied health professionals. About 80% of respondents worked at pediatric hospitals or pediatric spaces within adult hospitals, and 82% were academic, with the majority (57%) seeing 150+ unique AIS patients annually. Most respondents recommended six-month follow-up for patients under observation (60%) and bracing (54%). Most respondents (75%) considered family history and pain important (69%), with the majority (69%) asking about pain at every visit. Across all time points, Adam's forward bend test, shoulder level, sagittal contour, trunk shift, and curve stiffness were all considered critically important (>60%). At the first visit, scapular prominence, leg lengths, motor and neurological examination, gait, and iliac crest height were also viewed as critical. At the preoperative visit, motor strength and scapular prominence should also be documented. About 39% of respondents use heat sensors to monitor bracing compliance, and average brace wear since the prior visit was considered the most important (85%) compliance data point. CONCLUSIONS: This study establishes recommendations for a 19-item minimum data set for clinical AIS evaluation, including history, physical exam, and bracing, to allow for future multicenter registry-based studies.

Shoulder External Over Internal Rotation Ratio Is Related to Biomechanics in Collegiate Baseball Pitching.

Altering baseball pitching mechanics affects both performance and the risk of injury. The purpose of this study is to investigate the relationships of shoulder external over internal rotation ratio (SEIR) and other shoulder rotational properties during physical exam and biomechanics of pitching for 177 collegiate baseball pitchers. The shoulder range of motion was quantitatively measured using a custom-made wireless device. Pitching motion data were collected at 240 Hz, and a custom program was created to calculate the throwing arm motion and loading during baseball pitching. Linear regression and analysis of variance tests were performed to investigate the relationships between the shoulder physical exam outcomes and throwing arm biomechanics. SEIR had significant correlations with shoulder horizontal adduction angle at foot contact, maximum shoulder external rotation angle, maximum shoulder linear velocity, and elbow angle at ball release. SEIR groups had significant differences in shoulder proximal force, adduction torque, internal rotation torque, and horizontal adduction torque, and in elbow medial force and varus torque. Glenohumeral internal rotation deficit and total rotational motion deficit had no relationships with throwing arm motions or joint loadings. Shoulder health should be monitored to improve understanding of pitching mechanics in collegiate baseball pitchers.

The Ultrasound Hepato-Jugular Reflux: Measuring the Hepato-Jugular Reflux with Ultrasound with Comparison to Invasive Right Heart Catheterization.

BACKGROUND: Ultrasound can overcome barriers to visualizing the internal jugular vein, allowing hepato-jugular reflux and jugular venous pressure measurement. We aimed to determine operating characteristics of the ultrasound hepato-jugular reflux and ultrasound jugular venous pressure predicting right atrial and pulmonary capillary occlusion pressures. METHODS: In a prospective observational cohort at three US academic hospitals the hepato-jugular reflux and jugular venous pressure were measured with ultrasound before right heart catheterization. Receiver operating curves, likelihood ratios, and regression models were utilized to compare the ultrasound hepato-jugular reflux and ultrasound jugular venous pressure to the right atrial and pulmonary capillary occlusion pressures. RESULTS: In 99 adults undergoing right heart catheterization, an ultrasound hepato-jugular reflux had a negative likelihood ratio of 0.4 if 0 cm and a positive likelihood ratio of 4.3 if ≥ 1.5 cm for predicting a pulmonary capillary occlusion pressure ≥ 15 mmHg. Regression modeling predicting pulmonary capillary occlusion pressure was not only improved by including the ultrasound hepato-jugular reflux (P < .001), it was the more impactful predictor compared with the ultrasound jugular venous pressure (adjusted odds ratio 2.6 vs 1.2). The ultrasound hepato-jugular reflux showed substantial agreement (kappa 0.76; 95% confidence interval, 0.30-1.21), with poor agreement for the ultrasound jugular venous pressure (kappa 0.11; 95% confidence interval, -0.37-0.58). CONCLUSION: In patients undergoing right heart catheterization, the ultrasound hepato-jugular reflux is reproducible, has modest impact on the probability of a normal pulmonary capillary occlusion pressure when 0 cm, and more substantial impact on the probability of an elevated pulmonary capillary occlusion pressure when ≥ 1.5 cm.

Development and Evaluation of a Wearable Simulator System.

Background: Peer physical examination is a clinical teaching-learning approach used for decades because of the convenient sample of peers for practicing. However, this approach has limitations when learning to assess abnormalities and threatens psychologically safe learning. A wearable simulator system was designed for learning physical examination skills to minimize ethical and learning challenges. Sample: The sample consisted of fifty prelicensure nursing students and ten faculty in an upper Midwest university. Method: The wearable simulator was constructed into a vest with RFID tags and ribcage landmarks. An observational, evaluative design was used for participants to rate seven categories during a one-hour evaluation session of the wearable simulator worn by a standardized patient trained to portray an individual with pneumonia. Results: Satisfaction was rated highly among participants. More than 80% of student participants indicated the wearable simulator promotes privacy and reduces embarrassment. Conclusion: The wearable simulator system offers a promising teaching-learning alternative with scenario-specific auscultation and palpation feedback to provide a safe, repeatable, and consistent simulation experience.

A different approach to teaching pre-clerkship students physical diagnosis: standardized patient instructor-senior medical student teaching teams.

BACKGROUND: Faculty have traditionally taught the physical examination (PE) to novice medical students (pre-clerkship students.), despite recruiting and cost issues and problems standardizing their approach. ACTIVITY: We present a model using standardized patient instructor (SPI)-fourth year medical student (MS4) teams to teach PE to pre-clerkship students, leveraging the benefits of co-teaching and peer-assisted learning. RESULTS: Surveys of pre-clerkship students, MS4s and SPIs indicate positive perceptions of the program, including MS4s reporting significant growth in their professional identities as educators. Pre-clerkship students' performance on the spring clinical skills exams was equivalent to or better than their peer performance pre-program implementation. IMPLICATIONS: SPI-MS4 teams can effectively teach novice students the mechanics and clinical context of the beginners' physical exam.

Beyond the Usual Suspects: Hereditary Hemochromatosis and Transaminitis in Primary Care.

An annual physical examination within a primary care setting, including evaluation of liver enzymes and abnormal serology, is incidental and often asymptomatic. Fatty liver is the most common etiology for transaminitis. Hepatobiliary imaging studies, viral hepatitis serology, evaluation of metabolic liver disease, and alcohol consumption history should be performed for transaminitis evaluation. In patients with prior history of excessive alcohol consumption, transaminitis is often assumed to be alcohol-related. It is prudent to evaluate other infectious and metabolic etiologies, which can change patient management. Iron studies, including ferritin and transferrin saturation, are performed to evaluate hereditary hemochromatosis (HH). We present the case of a 46-year-old patient who visited the clinic for a routine health checkup, during which elevated ferritin levels were detected. Subsequent diagnosis revealed hemochromatosis. The patient underwent phlebotomy, resulting in a reduction of ferritin levels.

A Case of Hand-Foot-and-Mouth Disease in an Adult Male.

Hand-foot-and-mouth disease (HFMD) is commonly seen in infants and children; less frequently, it may be seen in adults as well. The disease is usually associated with viral infections, including many variants of enteroviruses and coxsackieviruses. We discuss the case of a 39-year-old male who presented with constitutional symptoms, fever, and lesions on his hands, feet, and mouth. His children, who had been recently diagnosed with HFMD, were likely the source of his infection. A comprehensive history and physical examination enabled us to identify the lesions, some of which were faint and difficult to visualize. Viral panel testing indicated positive results for human rhinovirus/enterovirus. Treatment and testing associated with the patient's condition were supportive, largely based on the history and physical findings which helped us narrow down our differential diagnoses. Complete resolution of the symptoms within one to two weeks is generally expected in these patients.

Pediatric Murmurs.

Many healthy children may be found to have a murmur on physical exam. Whether this murmur is discovered at a routine health maintenance visit or as a result of a focused exam on a child with illness, it is just one finding and must be considered in the context of the child's history and other physical exam findings. Murmurs associated with heart defect or dysfunction occur most often in infancy. Most murmurs discovered in children, especially after infancy, between ages 3 to 6 and in young-adulthood, are innocent or benign murmurs and less likely a symptom of cardiac dysfunction or defect.

Internal medicine intern performance on the gastrointestinal physical exam.

OBJECTIVES: The gastrointestinal (GI) physical exam provides critical information about underlying disease states. However, since assessment of physical examination skills is rarely conducted as part of internal medicine residency training, little is known about resident performance on the GI physical exam. METHODS: During a clinical skills assessment that took place between November 2019 and February 2020, internal medicine interns examined the same patient with chronic liver disease while being observed by faculty preceptors. We compared the exam maneuvers performed with those expected by the faculty evaluators. We noted which maneuvers were performed incorrectly, whether physical exam technique correlated with identification of physical exam findings, and if performance on the physical exam was associated with building an appropriate differential diagnosis. This four-hour assessment was required for internal medicine interns within two different residency programs in the Baltimore area. RESULTS: More than half of the 29 participating interns (n=17, 58.6 %) received a "needs improvement" score on their physical exam technique. Technique was highly correlated with identifying the correct physical signs (r=0.88, p<0.0001). The most commonly excluded maneuvers were assessing for splenomegaly and hepatomegaly. The most commonly missed findings were splenomegaly and hepatomegaly. Most interns included chronic liver disease as part of their differential diagnosis even if they received "needs improvement" scores on physical exam technique or identifying physical signs. CONCLUSIONS: Internal medicine interns would benefit from learning an organized approach to the gastrointestinal exam. This would likely lead to increased identification of important gastrointestinal findings.

Attitudes and Factors Determining the Practice of Routine Medical Checkups in the People of Rawalpindi, Pakistan: A Cross-Sectional Study.

INTRODUCTION: Routine medical checkup (RMC) is a screening and preventive technique that is implied to detect non-communicable diseases (NCDs). This study aims to assess the awareness in public regarding RMC, the association between education level and level of familiarity regarding RMC, and factors that prevent and encourage the practice of RMC by the public. METHODS: This is a cross-sectional study carried out in Rawalpindi, Pakistan. Health professionals and individuals who refused to consent were excluded from the study. Data was collected using a mixed-mode questionnaire, and convenient sampling was used. The sample size was calculated to be 355 according to the WHO sample size calculator. A total of 356 individuals participated in this study after giving informed consent. Both male and female adults aged 18 or older and residents of Rawalpindi were included in the study. Individuals younger than 18 were excluded.  Results: Among the 356 study participants, 160 (45%) were males, and 196 (55%) were females. The mean age was 27.57±10.027. Among the total participants, 33 (9.3%) individuals had primary-level education, 100 (28.1%) individuals had secondary-level education, and 233 (62.6%) had graduate-level education. A total of 329 (92.9%) participants knew that RMCs could help in early diagnosis and treatment. On the contrary, only 154 (43.3%) people knew that RMCs involve screening all body tissues. Only 329 (92.4%) participants said that they were aware that timely diagnosis through RMC can lead to early treatment. Graduates were generally more aware of different aspects of RMCs, especially in the domains of awareness regarding what an RMC is and that RMC can help in timely diagnosis compared to participants who had primary or secondary level of education (p<0.001). Females had a greater overall awareness of RMCs than males (p<0.001). Graduates were more likely to undergo RMCs than people educated till the primary or secondary level (p<0.001). The most common reason for undergoing RMC was "just concerned about health," which was selected by 130 (36.5%) participants. The most common reason mentioned by participants for not having an RMC was ''heavy cost,'' mentioned by 104 (29.2%) participants.  Conclusion: Most of the participants of this study were well educated and were students in terms of profession. The majority of the study population knew that RMCs could help in early diagnosis and treatment. Awareness regarding RMCs was linked to educational level. Females had overall better knowledge regarding RMCs than men. The most common reported reason to have an RMC was a health concern, and the most common reported reason for not having an RMC was its high cost.

A Visual Diagnosis: Lipodystrophy.

Lipodystrophy syndromes are rare metabolic disorders characterized by local or generalized loss of adipose tissue, resulting in insulin resistance, dyslipidemia, and cosmetic disfiguration. The lipodystrophic phenotype is highly variable, with partial lipodystrophy often missed or misdiagnosed as other diseases from a lack of a proper physical examination and low physician awareness. Correct diagnosis is important for optimal treatment and follow-up strategies in these patients. The use of GLP-1 analogs has not been systematically evaluated in lipodystrophy and could be a potential precision medicine therapy. We aim to make the reader, particularly generalists or endocrinologists outside of tertiary referral centers, aware of the presentation and clinical features of partial lipodystrophy, emphasize the role of a full physical examination in diagnosis, and discuss therapeutic options, including GLP-1-based glycemic management illustrated by our clinical case.

A Case Report of Culture-Negative Necrotizing Fasciitis With Low Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score: A Diagnostic Dilemma.

The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is a diagnostic tool used to help clinicians identify necrotizing fasciitis (NF) in its early stages. This tool uses six laboratory values including the patient's white blood cell count, C-reactive protein level, serum sodium level, creatinine level, and hemoglobin level to help with risk stratification. Each of these laboratory values is assigned a point value and the total score is used to determine the likelihood that a patient has NF, with a score of 6 or higher considered to be strongly indicative. The LRINEC score has gained popularity in recent years, having been included in guidelines and society recommendations for the management of NF. However, some studies have challenged the validity of the LRINEC score. Prompt and accurate diagnosis of NF is imperative given the associated mortality rate, which can be as high as 30%-40%, especially if the diagnosis is delayed. We present a case of a patient with a delayed diagnosis of NF that was initially missed in the early stages in the setting of a low LRINEC, however, growing clinical suspicion eventually led to an accurate diagnosis and management.

Exame físico em ginecologia / Physical examination in gynecology

O exame físico na prática ginecológica diuturna é o sustentáculo de uma perspectiva diagnóstica com vistas a uma abordagem individualizada, oportuna e humanizada da paciente. Lança mão de técnica semiótica clássica, inicialmente, após avaliação de sinais vitais, minuciosa inspeção ectoscópica, seguida de exame físico especial. E deverá ser realizado em ambiente adequadíssimo, sem nenhuma improvisação e ou adaptações não compatíveis, com a importância e a segurança garantidas por um exame físico de boa qualidade. O exame físico de mamas tem como objetivo primordial a identificação de nódulos mamários e, eventualmente, de tumores localmente avançados; e relativa tranquilidade é assegurada às pacientes quando ele é considerado normal. O exame físico vulvar permite a identificação de prolapso de órgãos pélvicos, neoplasia intraepitelial e/ou invasiva vulvar e distúrbios de desenvolvimento sexual, além de oferecer subsídios para a propedêutica da vulvodínea, sendo, principalmente, uma oportunidade para o diagnóstico em dermatologia vulvar, mesmo a vulva correspondendo a apenas 1% da pele feminina. O exame especular, um clássico da ginecologia, é indispensável para a triagem do câncer de colo uterino. Por fim, o toque genital, a despeito de sua subjetividade, permite a avaliação dos órgãos genitais internos.

Physical examination in daytime gynecological practice is the mainstay of a diagnostic perspective with a view to an individualized, timely and humanized approach to the patient; resorting to the classical semiotic technique, initially, after assessing vital signs, a thorough ectoscopic inspection, followed by a special physical examination; which should be carried out in a very suitable environment, without any improvisation or adaptations that are not compatible with the importance and safety guaranteed by a good quality physical examination. The primary objective of the physical examination of the breasts is to identify breast nodules and possibly locally advanced tumors; in addition to relative tranquility, assured to patients, when the respective exam is considered normal. Vulvar physical examination allows the identification of pelvic organ prolapse; vulvar intraepithelial and/or invasive neoplasia; sexual development disorders; in addition to offering subsidies for the propaedeutics of vulvodynia; and, above all, it is an opportunity for diagnosis in vulvar dermatology, even though the vulva accounts for only 1% of female skin. Specular examination, a classic in gynecology, is essential for screening for cervical cancer. Finally, the genital touch which, despite its subjectivity, allows the evaluation of the internal genital organs.