A Case of Green Nail Syndrome Diagnosed in the Emergency Department.

Green nail syndrome (GNS) is a rare diagnosis in which a patient presents with green-yellow, green-blue, or green-brown discoloration of a finger or toenail. It occurs due to a Pseudomonas aeruginosa infection of the nail. Pseudomonas aeruginosa produces pigments that can infuse into the underside of the nail plate, creating a color change. Here, we present the case of a 34-year-old female with a green-brown area of discoloration of her right middle finger in which the diagnosis of GNS was made. The patient used acrylic nails, which is a known risk factor. The characteristic clinical context and physical exam findings of green-yellow, green-blue, or green-brown nail discoloration are said to be sufficient to make a working diagnosis of GNS. The differential diagnosis of GNS includes a subungual hematoma, a subungual melanoma, and exogenous yellow pigment exposure. The history, physical examination, and response to treatment will help to clarify the differential. Ciprofloxacin is a commonly used empiric treatment. Laboratory testing of a nail clipping can be used in cases that do not respond to treatment. Cultures of nail clippings appear to be specific, but not sensitive, to the detection of P. aeruginosa. Our patient saw an immediate improvement within a week of treatment, with complete resolution in eight weeks. This is a typical timeframe. Knowledge of the syndrome can be helpful to reduce patient anxiety and guide effective therapy.

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.

Utilization of Video Otoscopes for Otoscopy Skills Training of Third Year Medical Students.

Purpose: Effective teaching and assessment of otologic examinations are challenging. Current methods of teaching otoscopy using traditional otoscopes have significant limitations. We hypothesized that use of all-in-one video otoscopes provides students with an opportunity for real-time faculty feedback and re-practicing of skills, increasing self-reported confidence. Methods: An otoscopy microskills competency checklist was provided to third-year medical students during their pediatric clerkship to self-assess otoscopy technique during patient examinations, and to clinical preceptors to assess and provide feedback during exams. Over the course of two years, we collected data from students randomly assigned to train on a video otoscope or a traditional otoscope during the clerkship. Pre- and post-clerkship surveys measured confidence in performing otoscopy microskills, making a diagnosis and documentation of findings. For those students who trained on the video otoscope, we solicited post-clerkship feedback on the experience of using a video otoscope. Results: Pre-clerkship confidence did not differ between the groups, but the video otoscope trained group had significantly higher scores than the traditional otoscope trained group on all self-reported technical and diagnostic microskills confidence questions items post-clerkship. Students trained on video otoscopes had a significant increase in confidence with all microskills items (p-values<0.001), however confidence in the traditional otoscope trained group did not change over time (p-values>0.10). Qualitative feedback from the video otoscope trained group reflected positive experiences regarding "technique/positioning" and "feedback from preceptors.". Conclusion: Teaching otoscopy skills to pediatric clerkship medical students using a video otoscope significantly enhanced confidence compared to those training on a traditional otoscope by 1. enabling preceptors and students to simultaneously visualize otoscopy findings 2. allowing preceptors to provide real-time feedback and 3. providing opportunity for deliberate practice of microskills. We encourage the use of video otoscopes to augment student confidence and self-efficacy when training in otoscopy.

Polycystic Ovarian Syndrome in Adolescents.

Polycystic ovarian syndrome (PCOS) is a metabolic, reproductive, and psychological complex series of disorders that impacts a woman throughout her lifespan. PCOS is a disorder of hormonal imbalance occurring in women of reproductive age. This disorder is characterized by high levels of male androgens like testosterone. This can lead to symptoms like irregular periods, amenorrhea (absence of menstruation), anovulation (absence of ovulation), hirsutism, acne, and obesity. PCOS also causes metabolic impairment. Multiple peripherally arranged immature follicles of about 2-5mm in diameter are present in the ovary. These follicles do not mature due to hormonal imbalances leading to an irregular menstrual cycle. PCOS is a metabolic, reproductive, and psychological complex series of disorders that impacts a woman throughout her lifespan. Polycystic ovarian syndrome is not a fatal or life-threatening disorder as its main complication is infertility. PCOS can be a root cause of serious medical conditions like obesity, hypertension, type-2 diabetes mellitus due to insulin resistance, endometrial cancers, ovarian cancer, etc. Stress may cause the hormone levels in the pituitary to fluctuate. Since the menstrual cycle is hormone-based, there are apparent irregularities.

Severe Mitral Regurgitation Diagnosis Through Point-of-Care Ultrasound During Initial Physical Examination.

Mitral regurgitation is a common valvular disorder found in the general population with varying degrees of severity. The symptoms of this disorder correspond to the severity of regurgitation as well as its associated complications such as arrhythmias. Suspicion of mitral regurgitation is based on physical exam findings with diagnosis generally requiring confirmatory findings on transthoracic echocardiogram. However, asymptomatic patients with mitral regurgitation and limited sensitivity of cardiac auscultation to detect a murmur confound the diagnosis. In this case, a patient presented with nonspecific symptoms of shortness of breath and abdominal pain in which a bedside point-of-care ultrasound (POCUS) in initial examination demonstrated severe mitral regurgitation and pulmonary edema. These findings expedited an intervention on the regurgitation, which highlights the importance of incorporation and early use of POCUS during physical examination.

"The report of my death ": Exaggerated Predictions on the Demise of the Stethoscope.

The narrative of the rise and fall of the stethoscope is partly written. Medical historians agree on the rise in its use; however, on the decline, they are less certain. This article explores the previously unexamined and surprisingly long history of predictions of the stethoscope's demise. It also provides evidence to show that it is not yet extinct, although its applications are changing as it adapts to newer technology and recent public health measures. Primary sources include medical school curricula, books, medical journals, and popular literature. Trends and projections in patent applications for stethoscope modifications and sales of the instrument provide additional evidence for the robust position of the stethoscope in current American practice.

Bitemporal Obesity: An Overlooked Sign of Visceral Obesity?

With increasing rates of morbidity and mortality associated with visceral obesity, as well as its related cardiometabolic disorders, physical findings that aid in diagnosing patients at risk for such conditions are extremely useful. This brief report introduces the novel facial physical sign of bitemporal obesity, which the author observed in a patient and suggests to be associated with visceral obesity.

Psychosocial profiles and their correlation with physical diagnosis in temporomandibular disorders, a preliminary report.

OBJECTIVE: To assess representative psychosocial features in a group of temporomandibular disorder (TMD) patients from Jordan using Axis II of the Diagnostic Criteria for TMD (DC/TMD) protocol. METHODS: Ninety-eight TMD patients were examined according to Axis I DC/TMD protocol in addition to assessment of their pain-related disability, psychological distress, and stress reactivity. RESULTS: Just under half of the patients (49%) had high intensity of characteristic pain (self-reported TMJ-related pain) and one-third (32%) had high levels of pain-related disability. Furthermore, significant proportions of patients expressed moderate-severe degrees of distress and stress reactivity (41% and 39%, respectively). Significant correlations were identified between the Graded Chronic Pain Scale (GCPS) and each of the pain-related TMD subgroups. CONCLUSION: TMD patients are susceptible to high levels of pain-related psychosocial impairment, and clinicians should be aware of the possible correlations between the physical TMD diagnosis and specific psychosocial features during treatment planning.

Advances in physical diagnosis and treatment of male erectile dysfunction.

Erectile dysfunction (ED) is the most common male sexual dysfunction by far and the prevalence is increasing year after year. As technology advances, a wide range of physical diagnosis tools and therapeutic approaches have been developed for ED. At present, typical diagnostic devices include erection basic parameter measuring instrument, erection hardness quantitative analysis system, hemodynamic testing equipment, nocturnal erection measuring instrument, nerve conduction testing equipment, etc. At present, the most commonly used treatment for ED is pharmacological therapy represented by phosphodiesterase five inhibitors (PDE5i). As a first-line drug in clinical, PDE5i has outstanding clinical effects, but there are still some problems that deserve the attention of researchers, such as cost issues and some side effects, like visual disturbances, indigestion, myalgia, and back pain, as well as some non-response rates. Some patients have to consider alternative treatments. Moreover, the efficacy in some angiogenic EDs (diabetes and cardiovascular disease) has not met expectations, so there is still a need to continuously develop new methods that can improve hemodynamics. While drug have now been shown to be effective in treating ED, they only control symptoms and do not restore function in most cases. The increasing prevalence of ED also makes us more motivated to find safer, more effective, and simpler treatments. The exploration of relevant mechanisms can also serve as a springboard for the development of more clinically meaningful physiotherapy approaches. Therefore, people are currently devoted to studying the effects of physical therapy and physical therapy combined with drug therapy on ED. We reviewed the diagnosis of ED and related physical therapy methods, and explored the pathogenesis of ED. In our opinion, these treatment methods could help many ED patients recover fully or partially from ED within the next few decades.

The development of physical diagnosis: Historical perspectives

@#The history of physical diagnosis started with Hippocrates and his school. History taking, inspection, palpation, and sometimes immediate auscultation and examination of the urine are fundamental diagnostic tools. The Hippocratic Corpus and Galen’s authoritative theoretical writings dominate medical thinking for over 1000 years. Clinical examination advances through Vesalius and Morgagni’s discoveries of human dissection (1543) and pathologic anatomy (1761) respectively. The Vienna school through Auenbrugger introduces percussion in 1760. The Paris school formally establishes physical diagnosis with the invention of the stethoscope by Laennec in 1816.

Infective Endocarditis-Like Presentation of Felty Syndrome: A Case Report.

Felty syndrome (FS) and infective endocarditis (IE) can present with similar signs and symptoms. FS is a diagnosis of exclusion, which poses a challenge for the clinician since accurate diagnosis is required to treat this condition effectively. A 52-year-old woman with a 15-year history of rheumatoid arthritis (RA) was admitted due to dyspnea and pain in the right ankle and left arm for two weeks. She was hemodynamically stable and afebrile. Physical examination revealed right ankle swelling and tenderness, left forearm tenderness, abdominal distension, and swan-neck finger deformities. Laboratory tests were notable for pancytopenia with a white blood cell (WBC) count of 2900 × 103/µL (absolute neutrophil count (ANC) of 1800/µL). Rheumatoid factor and anti-cyclic citrullinated peptide tests were positive. Synovial fluid analysis of the right ankle showed no crystals or bacteria, and a WBC count of 192 × 103/µL. Left upper extremity computed tomography (CT) revealed two abscesses, in the forearm and elbow, respectively. CT chest and abdomen revealed a wedge-shaped consolidation in the left upper lobe, multiple bilateral pulmonary nodules, and splenomegaly. Abdominal ultrasonography showed portal hypertension with no clear findings of cirrhosis. Blood cultures were negative. Transthoracic echocardiography (TTE) and transesophageal echocardiography showed no vegetation. Incision and drainage were performed for the right ankle swelling, and left forearm and elbow abscesses. Left forearm abscess culture revealed Staphylococcus hemolyticus. Transbronchial needle aspiration and culture of the left upper lobe lesion showed acute and chronic inflammation with no signs of malignancy or microbial growth. Repeat TTE and blood cultures were negative. Bone marrow biopsy and flow cytometry showed no evidence of large granular lymphocytic (LGL) leukemia. The patient was diagnosed with FS complicated by disseminated infections and pulmonary necrobiotic nodules. Empiric ceftriaxone and vancomycin were initiated. The patient was discharged after the resolution of her symptoms. FS is a rare extra-articular presentation of RA with a triad of a > 10-year history of RA, neutropenia (ANC < 2000/µL), and splenomegaly. IE can also present with disseminated infections and splenomegaly. Repeat TTE and blood cultures were performed due to concerns regarding the high mortality rate of IE and the possibility of false-negative echocardiography results. LGL leukemia also presents with RA and neutropenia, which was deemed less likely in our patient based on unremarkable bone marrow biopsy and flow cytometry results. FS is a rare condition. Therefore, it is important to keep its possibility in mind in the setting of RA while performing workup for the most likely conditions.

Abdominal Pain and Examination of Hernial Orifices: The Forgotten Art of Physical Diagnosis.

INTRODUCTION: Acute abdominal pain can be the first manifestation of a hernial pathology. The estimated risk of incarcerated hernia is 1%-3% over a person's lifetime. Therefore, hernial orifice examination should be conducted routinely, especially in cases of abdominal pain. We hypothesized that physical examination of hernial orifices is not routinely performed and documented in patients presenting with acute abdominal pain. METHODS: A retrospective chart review of 100 patients who were evaluated for abdominal pain over a three-month time frame at our institution. RESULTS: From the 100 reviewed cases, the hernial orifice examination was performed in two cases by an Internal Medicine or Emergency Medicine physician (2%). Out of the eight cases with General Surgery consultation, only one case had hernial orifices examination (12.5%). In the 10 cases with Gastroenterology consultation, not a single case had hernial orifice examination. CONCLUSION: We demonstrate that hernial examination is infrequently performed in clinical practice and suggest that emphasis should be placed on the efficient performance of physical examination and maintain the art of physical diagnosis.

Auscultation of Bowel Sounds and Ultrasound of Peristalsis Are Neither Compartmentalized Nor Correlated.

Objective  Auscultation of bowel sounds has been taught as a component of the physical examination since the beginning of the 20th century. However, there has been little research or consensus on the significance of listening in different quadrants. Some textbooks indicate that bowel sounds are the result of peristalsis in that region, while others state that bowel sounds can be generalized over the entire abdominal wall. With ultrasonography, peristalsis can be visualized in a dynamic and non-invasive manner. The purpose of this study was to determine the relationship between auscultation of bowel sounds and visualization of peristalsis with ultrasound, to understand whether or not bowel sounds and peristalsis are compartmentalized. Methods  Study participants quietly lay supine, while one investigator positioned an ultrasound probe on the abdomen visualizing the small intestine, and a second investigator placed an EKO Digital Stethoscope (Eko Devices, Inc., Oakland, CA) directly adjacent to the probe auscultate for bowel sounds. During a two-minute interval, a third investigator noted every time a bowel sound was heard (A+), peristalsis was seen (U+), or a combined event (C+) occurred, recording the total number of events. Measurements were recorded from four quadrants (right upper quadrant {RUQ}, left upper quadrant {LUQ}, right lower quadrant {RLQ}, left lower quadrant {LLQ}) and the periumbilical region (PUR). Fisher Exact test was used to determine whether there were significant differences between the number of bowel sounds heard but not seen (A+) and those seen but not heard (U+) with sounds that were both seen and heard (C+). Significance was determined with p < 0.05. Results  A total of 16 participants were included, with a combined 973 discrete bowel events, both auscultated and visualized. No quadrant showed a significant correlation between an isolated sound (A+) or peristalsis (U+) and a combined event (C+), indicating there were many events where an auscultated sound failed to correlate with observed peristalsis, and vice versa. The average p-value was 0.544, with a range of 0.052-1.00. Conclusion  This study showed that there is no significant correlation between auscultated bowel sounds and peristalsis within a given region. This study calls into question whether auscultation of all four quadrants provides more meaningful information than auscultation of one central point of the abdomen.

Medial tibial stress fracture diagnosis and treatment guidelines.

OBJECTIVES: To validate and make evidence based changes to the Israel Defense Forces medial tibial stress fracture diagnosis and treatment protocol. DESIGN: Prospective cohort study. METHODS: 429 Elite infantry recruits were reviewed for signs and symptoms of medial tibial stress fracture during 14 weeks of basic training. Suspicion of medial tibial stress fracture was based on the presence of pain, tenderness <1/3 the length of the tibia and a positive fulcrum and/or hop test. Recruits with suspected medial tibial stress fractures were initially treated with 10-14 days of rest. Bone scan was performed only when recruits failed to respond to the rest regimen or required immediate diagnosis. RESULTS: 31 Out of 49 recruits with a suspicion of medial tibial stress fracture underwent bone scan, including 8/26 recruits whose symptoms did not resolve after being treated clinically as stress fractures. There was a significantly greater incidence of medial tibial stress fractures when a positive hop test was present in addition to tibial pain and tenderness (p=0.0001), odds ratio 52.04 (95% CL, 2.80-967.74). Medial tibial stress fracture was found to occur when the band of tibial tenderness was ≤10cm in length. Tibial pain scores were not predictive of stress fracture. CONCLUSIONS: This validation study provides the clinician with evidence based guidelines for the clinical diagnosis and treatment of medial stress fractures and their differentiation from shin splints. An initial treatment protocol without the use of imaging was found to be effective in more than two-thirds of the cases.

Diagnosis and treatment of transthyretin-related amyloidosis cardiomyopathy.

Transthyretin-related amyloidosis (ATTR) is a subgroup of amyloidosis that results from extracellular misassembled and toxic amyloid deposits affecting multiple organ systems, and cardiac tissues in particular. Because ATTR often presents as heart failure with preserved ejection fraction (HFpEF), it has been largely underdiagnosed. Once considered incurable with a grave prognosis, ATTR cardiomyopathy has seen the development of promising alternatives for diagnosis and treatment, with early diagnosis and treatment of ATTR cardiomyopathy highly beneficial due to its high mortality rate. For instance, diagnosing ATTR cardiomyopathy previously required a cardiac biopsy, but new modalities, such as cardiac magnetic resonance imaging and radionuclide bone scans, show promise in accurately diagnosing ATTR cardiomyopathy. Ongoing research and clinical trials have focused on identifying new treatments which primarily target amyloid fiber formation by inhibiting TTR gene expression, stabilizing the TTR tetramer, preventing oligomer aggregation, or affecting degradation of amyloid fibers. In this review, we describe the advances made in the diagnosis and treatment of ATTR in order to increase awareness of the disease and encourage a lower threshold for ATTR workup. Our review also highlights the need for improving the screening, diagnosis, and treatment guidelines for ATTR cardiomyopathy.

Alternativa metodológica para el diagnóstico físico del escolar ciego desde el contexto de la Educación Física / Alternativa metodológica para o diagnóstico físico da criança cega do contexto da Educação Física / Methodological alternative for the physical diagnosis of the blind schoolchild from the context of Physical Education

Resumen Son limitados los estudios realizados en función de valorar el componente físico, en edades tempranas del desarrollo y enfocados a la ceguera. La mayoría de los estudios relacionados con la ceguera se realizaron con el fin de contribuir al desarrollo de la motricidad y no al estudio del componente físico; es por ello que, la investigación transitó desde el diagnóstico físico actual del escolar ciego, la selección de métodos y pruebas funcionales con sus adaptaciones, así como la valoración de la viabilidad de su aplicación en la enseñanza especial. Se constató que el diagnóstico pedagógico integral posee limitaciones ya que no incluye aspectos del componente físico, lo cual entorpece la adecuada dirección del proceso pedagógico de la Educación Física Especial. En este estudio, se utilizaron métodos del nivel empírico y del nivel teórico, alcanzando una gran significación el estudio de casos. De manera general, se constata que no se aplican, desde los Centros de Diagnóstico y Orientación, pruebas que permitan evaluar el componente físico de los escolares ciegos, lo cual atenta contra la calidad del proceso docente de la Educación Física.

Síntese Os estudos são limitados em termos de avaliação do componente físico em idades precoces de desenvolvimento e focando a cegueira. A maioria dos estudos relacionados com a cegueira foi realizada com o objectivo de contribuir para o desenvolvimento das capacidades motoras e não para o estudo da componente física. Assim, a investigação partiu do diagnóstico físico atual do aluno cego, da seleção de métodos e testes funcionais com as suas adaptações, bem como da avaliação da viabilidade da sua aplicação na educação especial. Verificou-se que o diagnóstico pedagógico abrangente tem limitações, uma vez que não inclui aspectos do componente físico, o que dificulta a direção adequada do processo pedagógico da Educação Física Especial. Neste estudo, foram utilizados métodos a partir do nível empírico e do nível teórico, tendo o estudo de caso alcançado grande significado. Em geral, verificou-se que os centros de diagnóstico e orientação não aplicam testes para avaliar o componente físico dos alunos cegos, o que prejudica a qualidade do processo de ensino da Educação Física.

Abstract Studies are limited in terms of assessing the physical component at early ages of development and focusing on blindness. Most of the studies related to blindness were carried out in order to contribute to the development of motor skills and not to the study of the physical component. Therefore, the research evolved from a current physical diagnosis of the blind student, the selection of methods and functional tests with their adaptations, as well as the assessment of the viability of their application in special education. It was found that the comprehensive pedagogical diagnosis has limitations, since it does not include aspects of the physical component, which hinders the adequate direction of the pedagogical process of Special Physical Education. In this study, methods from both the empirical and theoretical levels were used, with the case studies being of great significance. In general, it has been observed that the Centos de Diagnóstico y Orientación do not apply tests to evaluate the physical component of blind schoolchildren, which affects the quality of the physical education teaching process.

Artificial Intelligence-Assisted Auscultation of Heart Murmurs: Validation by Virtual Clinical Trial.

Artificial intelligence (AI) has potential to improve the accuracy of screening for valvular and congenital heart disease by auscultation. However, despite recent advances in signal processing and classification algorithms focused on heart sounds, clinical acceptance of this technology has been limited, in part due to lack of objective performance data. We hypothesized that a heart murmur detection algorithm could be quantitatively and objectively evaluated by virtual clinical trial. All cases from the Johns Hopkins Cardiac Auscultatory Recording Database (CARD) with either a pathologic murmur, an innocent murmur or no murmur were selected. The test algorithm, developed independently of CARD, analyzed each recording using an automated batch processing protocol. 3180 heart sound recordings from 603 outpatient visits were selected from CARD. Algorithm estimation of heart rate was similar to gold standard. Sensitivity and specificity for detection of pathologic cases were 93% (CI 90-95%) and 81% (CI 75-85%), respectively, with accuracy 88% (CI 85-91%). Performance varied according to algorithm certainty measure, age of patient, heart rate, murmur intensity, location of recording on the chest and pathologic diagnosis. This is the first reported comprehensive and objective evaluation of an AI-based murmur detection algorithm to our knowledge. The test algorithm performed well in this virtual clinical trial. This strategy can be used to efficiently compare performance of other algorithms against the same dataset and improve understanding of the potential clinical usefulness of AI-assisted auscultation.

Analysis of micro-lecture demands on the teaching of physical diagnosis in Clinical Skills / 中华医学教育探索杂志

Objective To further improve the proficiency and accuracy of physical diagnosis of medical students. Methods On March 16th, 2018, a random questionnaire survey were conducted and Excel used to investigate and analyze the needs of junior medical students for the teaching of physical diagnosis from the perspectives of topic selection of micro-lecture, presentation, teaching hours etc.. Results A total of 174 questionnaires were distributed and were all took back. In the survey, 139 students (79.89％) hoped to apply micro-lecture to the teaching of physical diagnosis, 132 students (75.86％) thought that the proper time of micro-lecture for each physical examination item should be 2-5 minutes , 150 students (86.21％) expected to learn micro-lecture of physical diagnosis via WeChat. Physical examination items selected mostly by students were on heart , chest and nervous system . Conclusion Theoretically and technologically speaking, it is feasible to make micro-lecture of physical diagnosis. Therefore, we should actively carry out the micro-lecture of physical diagnosis to meet students' learning demands and improve their operation skills of physical diagnosis.