A Concise, but Rational,

Approach to the Clinical Exam

A Summary of the JAMA Rational Clinical Exam Series

Sammy H. Ali and Douglas Wright

Table of Contents

Evidence Based Medicine Basics .......................................................................................2

Respiratory Evaluation
Pulmonary Embolus .............................................................................................................3
Deep Vein Thrombosis..........................................................................................................3
Airflow Limitation.................................................................................................................4

Cardiovascular Evaluation
Peripheral Arterial Disease ....................................................................................................5
Cardiac Tamponade .............................................................................................................5
Aortic Dissection..................................................................................................................6
Abdominal Aortic Aneurism ...................................................................................................7
Congestive Hearth Failure .....................................................................................................7
Myocardial Infarction............................................................................................................8
Systolic Murmurs (AS, MR, TR)..............................................................................................10
Aortic Regurgitation .............................................................................................................12
Jugular Venous Pressur ........................................................................................................13
Hypovolemia .......................................................................................................................14
Carotid Bruits......................................................................................................................15
Abdominal Bruits .................................................................................................................15

Abdominal Evaluation
Ascites ...............................................................................................................................16
Splenomegaly .....................................................................................................................17
Acute Cholecystitis...............................................................................................................18
Appendicitis ........................................................................................................................19
Acute Abdominal Pain Management........................................................................................19
Hepatomegaly .....................................................................................................................20
Dyspepsia...........................................................................................................................20

Musculoskeletal Evaluation
Osteoporosis .......................................................................................................................21

Neurological Evaluation
Stroke................................................................................................................................22
Myasthenia Gravis ...............................................................................................................23
Temporal Arteritis................................................................................................................24
Parkinson’s Disease .............................................................................................................25
Migraine .............................................................................................................................26
Vertigo ...............................................................................................................................27
Carpal Tunnel......................................................................................................................27

Infectious Disease Evaluation

Acute Meningitis ..................................................................................................................29
Influenza ............................................................................................................................30
Urinary Tract Infection .........................................................................................................31
Septic Arthritis ....................................................................................................................32
Sinusitis .............................................................................................................................33

General Patient Safety Evaluation

Depression .........................................................................................................................34
Patient Falls ........................................................................................................................34
Alcohol Abuse .....................................................................................................................34

Additional Evaluation
Breast Cancer .....................................................................................................................35
Thyroid Goiter .....................................................................................................................35
Clubbing.............................................................................................................................36
Melanoma...........................................................................................................................36
FHx of Cancer .....................................................................................................................37
Penicillin Alllergy .................................................................................................................38
Evidence Based Medicine Basics
Definitions

Sensitivity: Proportion of Patients with the condition that have a positive result. When a sign, test or symptom
has a high sensitivity, a negative result rules out the diagnosis
(SnOUT – sensitivity can be used to rule OUT a Dx).

Specificity: Proportion of Patients that do not have the condition that have a negative/absent result. When a
sign, test or symptom has an extremely high specificity (say, over 95%), a positive result tends to rule in the
diagnosis
(SpIN – specificity can be used to rule IN a Dx).

Positive Predictive Value: Proportion of people with a positive test who have the target disorder

Negative Predictive Value: Proportion of people with a negative test who do not have the target disorder

Positive Likelihood Ratio: the likelihood that a positive result would be expected in a patient with the target
condition compared to the likelihood that that same result would be expected in a patient without the condition.

Negative Likelihood Ratio: the likelihood that a negative result would be expected in a patient with the target
condition compared to the likelihood that that same result would be expected in a patient without the condition.

2 x 2 Table – Graphical Explanation of Above Application of Likelihood Ratios: The Nomogram

sensitivity = a/(a+c)
specificity = d/(b+d)
likelihood ratio (LR+) = sensitivity / (1-specificity)
likelihood ratio (LR-) = (1-sensitivity) / specificity

2
Respiratory Evaluation
Pulmonary Embolism
Does This Patient Have Pulmonary Embolism?
Sanjeev D. Chunilal; John W. Eikelboom; John Attia; Massimo Miniati; Akbar A. Panju; David L. Simel; Jeffrey S. Ginsberg
JAMA 2003; 290: 2849-2858.

Clinical Results:
Pretest Probability and Related Probability of having a PE based on different methods of clinical assessment.
Clinical Gestalt Clinical Rules
Low 8-19% 3-28%
Moderate 26-47% 16-46%
High 46-91% 38-98%

Bottom Line:
Clinical Prediction rules have similar accuracy to the clinical gestalt of experienced clinicians. For the
inexperienced, it is advised to use the rules to categorize patients into low, moderate and high probabilities.

Clinical Rules:

Deep Vain Thrombosis

Does This Patient Have Deep Vein Thrombosis?
Philip S. Wells; Carolyn Owen; Steve Doucette; Dean Fergusson; Huyen Tran. JAMA, January 11, 2006; 295: 199 - 207.

Clinical Results:
-Prevalence of DVT: low risk- 5.0%, moderate risk- 17%, and high risk- 53%
-Well’s Pretest Probability Model only validated for outpatients, NOT hospitalized pts
-D-Dimer Sen, Spec, -LR: low risk- 88%, 72%, 0.18, moderate risk- 90%, 58%, 0.19, high risk- 92%, 45%, 0.16
-High pretest probability pts have low specificity with D-dimer; therefore, do NOT use as screening test

Bottom Line:
Estimation of the pretest probability of DVT improves diagnostic accuracy. If the pretest probability is low
and the D-dimer is negative, DVT can be ruled-out; however, a high pretest probability requires diagnostic
testing to rule-out DVT.

3
Clinical Rules: Evidence:

Airflow limitation
Does the clinical examination predict airflow limitation?
Donald R. Holleman Jr., David L. Simel
JAMA. 273(4):313-9, 1995 Jan 25.

Clinical Results:
Increased probability of airflow limitation
-Presence of either wheezing (+LR 36, spec 99.6%) or barrel chest (+LR 10, spec 99%) virtually rules in
airflow limitation.
-Presence of decreased cardiac dullness (+LR 10), hyperresonance on percussion (+LR 4.8) or rhonchi (+LR
5.9) are highly suggestive as well.

Decreased probability of airflow limitation

-No single item or combination of items from the clinical exam rules out airflow obstruction.
-The best finding associated with decreased likelihood is a negative history of smoking (-LR 0.16), especially in
the absence of wheezing.

Evidence:

Historical Finding +LR -LR Physical Finding +LR -LR

Smoking: >70 vs <70 pack years 8 0.85 Wheezing 36 0.85
Smoking: ever vs. never 1.8 0.16 Barrel chest 10 0.9
Sputum Production > 1/4 cup 4 0.84 Decreased cardiac dullness 10 0.88
Symptoms of chronic bronchitis 3 0.78 Match test 7.1 0.43
Wheezing 3.8 0.66 Rhonchi 5.9 0.95
Coughing 1.8 0.69 Hyper-resonance 4.8 0.73
Any Dyspnea 1.2 0.55 Subxyvoid cardiac impulse 4.6 0.94
Pulsus paradoxus 3.7 0.62
Decreased breath sounds 3.7 0.7
Accessory muscle use - 0.7

4
Cardiovascular Evaluation
Peripheral Arterial Disease
Does the Clinical Examination Predict Lower Extremity Peripheral Arterial Disease?
Nadia A. Khan; Sherali A. Rahim; Sonia S. Anand; David L. Simel; Akbar Panju. JAMA 2006; 295: 536-546.

Physical Exam:
-Ankle-Brachial Index (ABI): Ratio of highest systolic BP of the ankle (dorsalis pedis and/or posterior tibialis)
divided by the brachial BP, most accurately taken with the pt supine and the cuff placed 2-3 cm above the
measured pulse detected by the hand-held Doppler. ABI <0.90 has sen 95% and spec 100% of detecting PAD
as compared to angiogram. Falsely high values can occur with non-compressible vessels, associated with an
increased mortality.
-Capillary Refill Time- firm pressure is applied to the plantar aspect of the great toe for 5 seconds. Longer
than 5 seconds for normal skin color to return after pressure release is considered abnormal
-The Buerger test- while the patient is supine, the development of pallor with the patient’s leg elevated to 90°
is observed then the leg is lowered slowly and the angle at which the reddish hue returns is known as the “angle
of circulatory sufficiency”; the result is positive if the angle is less than 0° (ie, below the examining table)
-Venous Filling Time- identify a visible vein at the ankle area with the patient supine then lift the patient’s leg
45° above the examining table for 1 minute while observing the vein for a normal collapse. With the patient
then positioned to sitting and dangling his/her legs, measures the length of time it takes for the vein to refill; an
abnormal venous filling time is longer than 20 seconds.

Clinical Results:
Increase Probability of PAD (+LR):
Asymptomatic Patient: Claudication (3.30), Femoral Bruit (4.80), any pulse abnormality (3.10), prolonged
venous filling time for moderate to severe disease (ABI <0.50) (3.60)
Symptomatic Patient: presence of cool skin (5.90), at least 1 bruit (5.60), pulse abnormalities (any pulse 4.70,
femoral pulse 7.20, Posterior Tibialis 8.10, Dorsalis Pedis 1.90)

Decrease Probability of PAD (-LR):

Asymptomatic Patient: No Finding decreases the probability of PAD, but can reduce the likelihood of moderate to
severe disease with the absence of claudication, presence of normal pulses
Symptomatic Patient: absence of bruits (0.39) or pulse abnormalities (0.38)

*Combinations of physical signs for the Dx of PAD does NOT increase the likelihood of PAD, but multiple
normal signs do decrease the likelihood of Dx beyond the population baseline

Bottom Line:
Clinical signs are not sufficient in to rule in or out PAD without a pretest probability. The hand-held Doppler
has the greatest accuracy to screen for PAD.

Cardiac Tamponade
Does This Patient With a Pericardial Effusion Have Cardiac Tamponade?
Christopher L. Roy; Melissa A. Minor; M. Alan Brookhart; Niteesh K. Choudhry. JAMA, April 25, 2007; 297: 1810 - 1818.

Physical Exam:
Pulsus Paradoxus: exaggeration of the normal physiological drop in systolic BP > 10 mmHg during inspiration
compared to expiration.

Clinical Results:
-The majority of pts with cardiac tamponade at least one of tachycardia, dyspnea, elevated JVP, and
cardiomegaly on CXR.
-Pulsus Paradoxus of over 10 mmHg is helpful in the Dx and less than 10 mmHg is helpful to reduce the
likelihood.

5
Bottom Line:
Most patients with cardiac tamponade will have at least one sign/symptom and pulsus paradoxus is helpful, but
further testing is required for definite dx.

Evidence:
Table 1 - Sensitivity of the Physical Examination in the Diagnosis of Cardiac Tamponade
Sign Pooled Sensitivity %
Pulsus Paradoxus > 10mm Hg 85
Tachycardia 77
Hypotension 26
Hypertension (sys bp> 140) 33
Tachypnea 80
Diminished Heart Sounds 28
Elevated JVP 76
Peripheral Edema 21-28
Pericardial Rub 19-29
Hepatomegaly 28-55
Kussmaul Sign 26
Pulse Pressure, mm Hg
>0 54
>100 12
Total Parodox 23
Cardiomegaly on CXR 89 (73-100)
ECG Findings
Low Voltage 42 (32-53)
Atrial Arrythmia 6 (1-11)
Electrical Alternans 16-21
ST-segment elevation 18-30
PR-segment depression 18

Aortic Dissection
Does This Patient Have an Acute Thoracic Aortic Dissection?
Michael Klompas . JAMA, May 2002; 287: 2262 - 2272.

Clinical Results:
-Highest Sensitivities: sudden onset (84%) of severe pain (90%)

Increase the Probability of Aortic Dissection (+LR):

Blood pressure differential between arms (5.7), neurological deficits (6.6-33.0), Marfan Syndrome (4.1), tearing
or ripping quality of pain (1.2-10.8), migratory pain (1.1-7.6)

Decrease the Probability of Aortic Dissection (-LR):

Absence of sudden onset of pain (0.3), no change in aorta or mediastinum on CXR (0.3)

Bottom Line:
The before mentioned findings alter the likelihood of an aortic dissection; however, these clinical and CXR
findings cannot be used to rule out the Dx due to its severe morbidity. The results must be accepted with
caution, as a prospective, blinded study has not been done.

Evidence:
Symptom or Sign Positive LR Negative LR
Hx of HTN 1.5 (1.2-2.0) 0.5 (0.3-0.7)
Sudden Chest Pain 1.6 (1.0-2.4) 0.3 (0.2-0.5)
Tearing/Ripping Chest Pain 1.2-10.8 0.4-0.99
Migrating Pain 1.1-7.6 0.6-0.97
Pulse deficit 5.7 (1.4-23.0) 0.7 (0.6-0.9)
Focal Neurological Deficit 6.6-33.0 0.71-0.87
Diastolic Murmur 1.4 (1.0-2.0) 0.9 (0.8-1.0)
Englarged Aorta or wide mediastinum 2 (1.4-3.1) 0.3 (0.2-0.4)
LVH 0.2-3.2 0.84-1.2

6
Abdominal Aortic Aneurism (AAA)
Does this patient have abdominal aortic aneurysm?
Frank A. Lederle, David L. Simel. JAMA. 281(1):77-82, 1999 Jan 6.

Physical Examination:
AAA palpation: patient supine with knees raised with relaxed abdomen, feel for aortic pulsation few cm
cephalad of umbilicus. Position hands on abdomen palms down and place index fingers on either side of
pulsating area to measure aortic width (normal aorta <2.5cm width, plus take into account skin thickness).

Clinical Rules:
- Sensitivity of AAA palpation increases with AAA diameter: quite low for 3.0-3.9cm AAAs (29%, +LR 12) to
76% for >5.0cm AAAs (+LR 15.6).
- Roughly 43% of AAA’s found to be large on physical exam will be supported by ultrasound findings.

Bottom Line:
Abdominal exam will detect ¾ of AAAs that are large enough to warrant surgery, but cannot be relied upon to
exclude the diagnosis. Although a positive exam increases the likelihood of AAA diagnosis significantly,
roughly half of these cases will be excluded on U/S (safe and relatively inexpensive test).

Evidence:

Table 1: Accuracy of Abdominal Palpation for detecting AAA (using >3cm or >4cm cutoff point)
Cutoff Point >3.0cm Cutoff Point > 4.0cm
Positive LR Negative LR Positive LR Negative LR
12.0 (7.4-19.5) 0.72 (0.65-0.81) 15.6 (8.6-28.5) 0.52 (0.38-0.67)
*pooled results from numerous trials

Table 2: Sensitivity of Abdominal Palpation for detecting AAA of various diameters

3.0-3.9cm 4.0-4.9cm >5.0cm
Sensitivity 29% 59% 76%
*pooled results from numerous trials

Congestive Heart Failure

Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure?
Charlie S. Wang; J. Mark FitzGerald; Michael Schulzer; Edwin Mak; Najib T. Ayas. JAMA, October 19, 2005; 294: 1944 - 1956.

Clinical Results:
Increase Probability CHF (+LR):
Past hx of CHF (5.8), PND (2.6), CXR with pulmonary venous congestion (12) or interstitial edema(12),
S3 gallop (11), abdominojugular reflux (6.4), ECG with Afib (3.8)

Decrease Probability of CHF (-LR):

Absence of past Hx of CHF(0.45), rales (0.51), dyspnea on exertion (0.48), CXR cardiomegaly (0.33),
BNP <100 pg/ml (0.11)

Bottom Line:
With a dyspneic patient, a physical exam, hx, and CXR are beneficial to assist in establishing the Dx, using the
BNP for the low suspicious pts to assist in ruling out the Dx. The LRs change with COPD and asthma.

Evidence:

7
Myocardial Infarction
Is this patient having a myocardial infarction?
Akbar A. Panju, Brenda R. Hemmelgarn, Gordon H. Guyatt, David L. Simel JAMA. 280(14):1256-63, 1998 Oct 14.

Background:
-Differential for ischemic cardiac pain includes non-ischemic cardiac (i.e. pericarditis, aortic dissection) and
non-cardiac causes (i.e. GERD, PUD, pneumothorax, PE, MSK, panic attack).
-Diagnosis of MI is confirmed with ischemic ECG changes (STEMI vs. NSTEMI) and presence of cardiac
enzymes (CK/troponin)

Clinical Rules:
Increased probability of MI:
-Pain radiation to both left and right arms (+LR 7.1) is the best indicator that a patient is having an MI.
Hypotension (+LR 3.1), Right shoulder radiation (+LR 2.9) and pain in left arm (+LR 2.3) also all increases the
likelihood.

Decreased probability of MI:

Pleuritic chest pain, sharp/stabbing chest pain, positional chest pain, and reproducibility by palpation all reduce
the likelihood that a patient is having an MI.

Bottom Line:
Although diagnosis is made by EKG and blood chemistry, pretest probability can be dramatically affected by
radiation and quality of the chest pain.

8
Evidence:

Is This Patient Dead, Vegetative, or Severely Neurologically Impaired?: Assessing Outcome for Comatose Survivors of Cardiac
Arrest
Christopher M. Booth; Robert H. Boone; George Tomlinson; Allan S. Detsky. JAMA 2004; 291: 870-879.

Clinical Results:
Most predictive of death and poor neurological outcome-
At 24 hours: absent corneal reflexes, papillary response, withdrawal to pain, and motor response (also at 72
hours)
*No clinical findings strongly predicted good outcome

Bottom Line:
The prognosis comatose survivors of cardiac arrest can be strongly predicted with simple physical exam
maneuvers, the most useful after 24 hours. Physical exam should not be used to provide treatment
recommendations or be used prior alone before 24 hours.

9
Systolic Murmurs
Does this patient have an abnormal systolic murmur?
Edward Etchells, Chaim Bell, Kenneth Robb. JAMA. 277(7):564-71, 1997 Feb 19.

Aortic Stenosis

Physical Examination:
Apical-carotid delay: simultaneously palpate PMI and right carotid artery for delay, which if present is
abnormal
Brachioradial delay: simultaneously palpate right brachial artery w/ R-thumb and right radial artery w/ left
fingers to detect a delay, which if present is abnormal
Valsalva Manuever: have patient strain against a closed glottis (or sustained abdominal pressure) for 20sec and
note changes in murmur intensity. Valsalva decreases venous return and increases systemic arterial resistance,
decreasing intensity of AS murmur.

Clinical Results:
Increased probability of AS:
Presence of any of the following significantly increases likelihood of AS : slow rate of rise of carotid pulse
(+LR 130), peak murmur intensity in late or mid systole (+LR 8-100), decreased S2 intensity (+LR 50), apical-
carotid delay (+LR >2.4) and brachioradial delay (+LR 6.8).

Decreased probability of AS:

The absence of radiation to the right carotid significantly reduces likelihood of AS (-LR 0.05).
Evidence:

10
Mitral Regurgitation

Physical Exam:
Transient Arterial Occlusion: Simultaneously inflate 2 BP cuffs around patient’s arms to approx. 20-40mmHg
above their systolic BP and check for change in murmur intensity. Increases systemic arterial resistence which
increases intensity of MR murmur.
- Alternatively can be done by having patient clench fists tightly, however no evidence supporting this method.

Clinical Results:
Increased probability of MR
Murmur location in the mitral area (+LR 3.9) and increase in murmor intensity with transient arterial occlusion
(+LR 7.5) increase likelihood of MR significantly.

Evidence:

Tricuspid Regurgitation

Physical Exam:
Quiet Inspiration: Determine effect of quiet inspiration (not deep breathing) on murmur intensity
Abdominal Pressure: Patient exerts firm, sustained pressure inward and cephalad below right costal margin.
*these maneuvers increase R-sided venous return and therefore should increase TR murmur intensity.

Clinical Results:
Increased probability of TR
Both quiet inspiration (+LR 8, -LR 0.2) and abdominal pressure (+LR 2.5-infinity, -LR 0.33) significantly
increase likelihood that murmur is TR. Absence of these findings decreases likelihood.

11
Aortic Regurgitation
Does this patient have Aortic Regurgitation?
Niteesh K. Choudhry and Edward F. Etchells JAMA. 281(23):2231-8, 1999 Jun 16.

Physical Exam:
Transient Arterial Occlusion: Simultaneously inflate 2 BP cuffs around patient’s arms to approx. 20-40mmHg
above their systolic BP and check for change in murmur intensity. Increases systemic arterial resistence which
increases intensity of AR murmur.
- Alternatively can be done by having patient clench fists tightly, however no evidence supporting this method.
Popliteal-Brachial pulse gradient (Hill sign): Systolic BP in lower extremities at least 20mmHg higher than
in arms while supine.
Flint Murmur: low-pitched late-diastolic apical murmur best heard w/ patient in left lateral decubitus using
bell of stethescope.

Clinical Results:
Increased probability of AR
- popilteal-brachial gradient > 20mmHg (+LR 8.2) and increased intensity with transient arterial occlusion (+LR
8.4) are both very predictive of AR if present
-presence of Flint murmur increases the likelihood of moderate-greater AR significantly (+LR 25)

*it appears are though neither peripheral hemodynamic signs and pulse pressure >50mmHg have little use in
ruling in or out AR.

-peripheral hemodynamic signs included are Deroziez bruit, femoral pistol shots and Corigan pulses

12
Jugular Venous Pressure (JVP)
Does this patient have abnormal central venous pressure?
Deborah Cook, David L. Simel JAMA. 275(8):630-4, 1996 Feb 28.

Multiphasic Waveform:

Physical Examination:
JVP:
-Well-lit room (tangential lighting), angle patient usually 30-45°
-Distinguish between JVP (biphasic wave, positional change, nonpalpable, occludable, positive abdominal-
jugular reflex) and carotid pulse (single sharp wave, no positional change, palpable, non-occludable, no
abdominal-jugular reflex)
-Measure vertical distance in centimeters from sternal angle of Louis to top of JVP; >4cm is elevated

Abdominojugular (Hepatojugular) reflux: Firm pressure (approx. 20-35mmHg) is applied w/ palm of hand to
midabdomen for 15-30sec. Positive test occurs when abdominal compression causes sustained increase of
>4cm.

Clinical Results:
Is the central venous pressure high?
Assessment of a JVP as being high on clinical exam increases the likelihood of high central venous pressure by
4-fold (+LR 4.1), while assessment of a JVP as being low makes it very unlikely that central venous pressure is
high (-LR 0.2).

Abdominojugluar reflux significantly increases the likelihood that a patient has CHF if positive (spec 96%, +LR
6.4), however if negative does not have any ability to rule out the condition (sens 24%).

Bottom Line:
-Clinical assessment of a JVP as either high or low has good predictive value of the central venous pressure,
however has little predictive value in describing normal CVP.
-Abdominojugular reflux is very useful in ruling in CHF if positive, but has little use in ruling it out if negative.

Evidence:

13
Hypovolemia
Is this patient hypovolemic?
Steven McGee, William B. Abernethy III, David L, Simel JAMA. 281(11):1022-9, 1999 Mar 17.

Physical Examination:
Orthostatic vitals
- When measuring postural vitals clinician should wait 2 minutes before measuring supine vitals, and 1
minute after standing before measuring standing vitals.
- Sitting instead of standing markedly decreases ability to detect hypovolemia due to blood loss.
Postural Pulse Increase is >30beats/min increase on standing
Postural Hypotension is >20mmHgdecrease of SBP on standing

Clinical Results:

Hypovolemia due to blood loss:

-Postural Pulse increment > 30mmHg on standing and/or severe postural dizziness is both the most specific and
sensitive indicator of hypovolemia secondary to severe blood loss, therefore presence/absence of these signs is
sufficient to rule-in/rule-out the condition.
-Although presence of postural hypotension (>20mmHg drop in SBP on standing) is excellent at ruling-in
hypovolemia secondary to severe blood loss, it adds little additional predictive value to the postural pulse +
postural dizziness combination.

Hypovolemia due to volume depletion (vomiting, diarrhea and decreased oral intake, but not blood loss):
-The presence of increased cap-refill time, dry axilla, sunken eyes and upper/lower extremity weakness are
useful for ruling in hypovolemia secondary to volume depletion.
-Absence of dry mucous membranes and lack of longitudinal furrows on tongue are powerful methods for
ruling out hypovolemia secondary to volume depletion.

Bottom Line:
-Presence of absence of a Postural Pulse increment > 30mmHg on standing and/or severe postural dizziness is
sufficient for ruling-in or ruling-out hypovolemia due to severe blood loss, however is less useful in mild blood
loss. Postural hypotension is less sensitive but also useful to help rule in.
-For other causes of hypovolemia (vomiting, diarrhea, decreased intake) increased cap-refill, dry axilla and
sunken-eyes are most useful to rule in and presence of moist mucous membrane most useful to rule out.

Evidence:

14
Carotid Bruit
Does this patient have a clinically important carotid bruit?
Jean-Stephane Suave, Andreas Laupacis, Truls Ostbye, Brian Feagan, David Sackett JAMA. 270(23):2843-5, 1993 Dec 15.

Physical Examination:
-It is conventional to use the bell of the stethoscope and listen for carotid bruits in area between thyroid
cartilage and jaw bilaterally.

Bottom Line:
-Although presence of carotid bruit in symptomatic patients increases likelihood that the stenosis is high grade,
accuracy is low.
-The presence of a carotid bruit cannot be used to either rule in or rule out surgically amenable carotid stenosis
in symptomatic patients.

Evidence:

Abdominal Bruits
Is Listening for Abdominal Bruits Useful in the Evaluation of Hypertension?
J.M. Turnbull
JAMA. 274(16):1299-301, 1995 Oct 25.

Clinical Results:
-the absence of an abdominal bruits has very little utility in ruling out renovascular hypertension (Sens 39-77%)
-the presence of an abdominal bruit in hypertensive patients is suggestive of renovascular hypertension,
especially if the bruit is both systolic & diastolic (Spec 99%, +LR 39)

Evidence:

15
Abdominal Evaluation
Ascites
Does this patient have ascites? How to divine fluid in the abdomen
John W. Willaims, Jr., David L. Simel
JAMA. 267(19):2645-8, 1992 May 20

Background:
-Ascites becomes clinically detectable when >500ml.

Physical Exam:
-Bulging Flanks: inspection of abdomen for absence/presence of bulging flanks
-Flank Dullness: percussion of flanks for dullness
-Shifting Dullness: first percuss and map border between tympany and dullness with patient supine, then have
patient turn onto one side and percuss for new border. In ascitic abdomen dullness will shift to dependant
portion.
-Fluid Wave: Have patient/assistant press both hands firmly down midline of patient’s abdomen. Take one
flank sharply with fingertip and feel opposite flank for transmitted impulse.

Clinical Results:
Ruling in Ascites:
-most powerful history findings are increased girth (+LR 4.16) and recent weight gain (+LR 3.2)
-most powerful physical exam finding is a positive fluid wave (+LR 6.0) and shifting dullness (+LR 2.7)

Ruling out Ascites:

-most useful history findings are negative histories of ankle swelling (-LR 0.10) or increased abdominal girth (-
LR 0.17)
-most useful physical exam finding are lack of bulging flanks (-LR 0.3), flank dullness (-LR 0.3) or shifting
dullness (-LR 0.3)

Evidence:

16
Splenomegaly
Does this patient have splenomegaly?
Steven A. Grover, Alan N. Barkun, David L. Sackett. JAMA. 270(18):2218-21, 1993 Nov 10.

Physical Examination:
Castell's Sign: with patient in supine position, percuss lowest intercostal space at the left anterior axillary line
during inspiration and expiration. In presence of splenomegaly percussion will remain dull during inspiration.
Traube's Space: cresent-shaped space depicted by the following surface markings - the left sixth rib, the left
anterior axillary line, and the left costal margin. Dullness to percussion in this space indicates splenomegaly.

Palpation of spleen should begin in the right lower quadrant and proceed towards the left upper quadrant in
order to follow the path of splenic enlargement.

Clinical Results:
Decreased probability of splenomegaly:
-Castell’s sign (when negative) has the best ability to decrease probability of splenomegaly (Sens 82%),
followed by traube’s space (Sens 78%). Palpation has very little predictive value if negative.

Increased probability of splenomegaly:

-Although castell’s and traubes can aid in ruling in splenomegaly, postive palpation has a very high likelihood
of indicating splenomegaly.

Bottom Line:
-Physical exam should begin with percussion (castell’s or traubes) and if there is no dullness there is no need to
proceed with palpation. (if suspicion is high enough then U/S should be used in this case)
-If percussion is dull then proceed with palpation. If both tests are positive then splenomegaly can effectively
be ruled-in.

Evidence:

17
Acute Cholecystitis
Does This Patient Have Acute Cholecystitis?
Robert L. Trowbridge; Nicole K. Rutkowski; Kaveh G. Shojania. JAMA 2003; 289: 80-86.

Physical Exam:
-Murphy’s Sign- on deep inspiration, the pt feels pain and arrests inspiration when the pressure is placed under the
right costal margin

Clinical Results:
Increase the Likelihood of Cholecystitis (+LR):
Murphy Sign (2.8)

Decrease the Likelihood of Cholecystitis (-LR):

Absence of Right Upper Quadrant Tenderness (0.4)

*Both CI include 1.0. No clinical or laboratory finding had sufficient LRs to rule in or rule out the Dx.
**Clinical Gestalt of experienced clinician: positive LR 25-30

Bottom Line:
Dx is dependent upon the combinations of factors synthesized by experienced clinicians and additional
diagnostic imaging.

Evidence:

18
Appendicitis
Does this patient have appendicitis?
James M. Wagner, Paul McKinney and John Carperter. JAMA. 276(19):1589-94, 1996 Nov 20.

Physical Examination:
Rebound Tenderness: apply pressure to abdomen with flat of hand for 30-60sec and without warning remove
hand suddenly and observe for pain on removal
Rovsing Sign: press deeply in LLQ and release pressure suddenly – positive sign is pain in RLQ
Psoas Sign: with patient supine, have them lift thigh against your hand placed just above their knee – increased
pain with maneuver is positive sign.
Obturator Sign: passively flex the right hip + knee and internally rotate the leg at the hip – increased pain with
maneuver is positive sign.

Clinical Results:
Increased probability of Appendicitis:
-most powerful history findings are classic migration of pain (+LR 3.2), RLQ pain (+LR 7.3) and pain before
vomiting (+LR 2.8)
-most powerful exam findings are rigidity (+LR 3.76), positive psoas and fever (+LR 1.94)

Decreased probability of Appendicitis:

-the absence of RLQ pain (-LR 0-0.28) and the presence of similar pain previously (-LR 0.323) are powerful
historical findings that make appendicitis less likely

Bottom Line:
-no finding on the clinical examination can effectively rule out appendicitis.
-presence of peritoneal signs (guarding, rebound, psoas, etc) are useful if present but not if absent

Acute Abdominal Pain Management

Do Opiates Affect the Clinical Evaluation of Patients With Acute Abdominal Pain?
Sumant R. Ranji; L. Elizabeth Goldman; David L. Simel; Kaveh G. Shojania. JAMA 2006; 296: 1764-1774.

Clinical Results:
Altered clinical findings were found in a number of studies; However, significant physical examination findings
(ex. Peritoneal signs) were not altered, leading to no significant changes in management or morbidity and
mortality.

Bottom Line:
Analgesia administration in management of abdominal pain does not have a negative impact on patient
outcome, although it can affect minor clinical signs.

19
Hepatomegaly
Physical Examination of the Liver
C. David Naylor. JAMA. 271(23):1859-65, 1994 Jun 15

Physical Examination:
-normal liver span <12-13cm at MCL on exam (varies with gender and height)
Palpation of lower edge: gentle pressure in RLQ; ask patient to breathe in bringing liver edge down to
examining fingertips. Move fingers up 2cm after each exhalation – mark lower edge at mid-clavicular line
(MCL)
Percussion of upper edge: percuss down from level of third rib at MCL until tympany changes to dullness.
Scratch Test: place the diaphragm over the area of the liver and then scratch parallel to the costal margin until
the sound intensity drops off marking the edge of the liver

Clinical Results:
-if liver is palpable on examination likelihood of hepatomegaly is increased (+LR 2.5)
-When assessing MCL liver span, individual techniques (scratch test, percussion or palpation alone) have
limited use in ruling out hepatomegaly, but this improves when all techniques are combined (Sens. 78%)

Evidence:
Table 1 – Probability of hepatomegaly if liver is palpable
Postive LR Negative LR
Pooled Results 2.5 (2.2-2.8) 0.45 (0.38-0.52)

Table 2 – Methods of estimating MCL liver span to assess for hepatomegaly

Physical Exam Sensitivity (%)
Scratch test 42
Percussion alone 40
Palpation alone 53
Palpation, percussion and scratch test 78
palpation and/or percussion 44
**all studies involved had limited number of patients

Dyspepsia
Can the Clinical History Distinguish Between Organic and Functional Dyspepsia?
Paul Moayyedi; Nicholas J. Talley; M. Brian Fennerty; Nimish Vakil. JAMA 2006; 295: 1566-1576.

Definition:
-Organic Dyspepsia: epigastric pain/discomfort with an abnormal Endoscopic investigation
-Functional Dyspepsia: epigastric pain/discomfort with a normal Endoscopic investigation

Clinical Results:
-Computer models and physicians are poor predictors of ruling-in or out organic dyspepsia, PUD, and
esophagitis.

Bottom Line:
Clinicians and Computer programs incorporating multiple factors do not correlate diagnosis with endoscopy of
dyspepsia.

20
Muskuloskeletal Evaluation
Osteoporosis
Does This Woman Have Osteoporosis?
Amanda D. Green; Cathleen S. Colón-Emeric; Lori Bastian; Matthew T. Drake; Kenneth W. Lyles. JAMA 2004; 292: 2890-
2900.

Physical Exam:
-Wall-Occiput Distance- determine kyphosis, a pt stands straight with back and heels touching a wall and a line from
lateral corner of eye to superior junction of auricle is parallel to the floor, the distance between the occiput and wall is
measured. +’ve= >0 cm
-Rib-pelvis distance- measure of lumbar fracture, pt stands with arms stretched to 90 deg in front while the examiner
stands behind and determines the number of fingers that fit between the inferior ribs and superior hip at the midaxillary
line
-Skinfold thickness- calipers used to measure the skin thickness on the back of the hand, often at the 4th metacarpal
-Hand Grip Strength- maximal force recorded while the pt hands arms outstretched to the side

Clinical Results:
Increase the Likelihood of Osteoporosis (+LR):
Weight <51kg (7.3), tooth count <20 (3.4), rib-pelvis distance <2 fingers (3.8), self-reported hump back (3.0),
and wall-occiput distance >0 cm (4.6)
Decrease the Likelihood of Osteoporosis (-LR):
Negative prediction rules (0.02-0.3) (ex. Osteoporosis Risk Assessment Tool)

Bottom Line:
No single examination finding can dx osteoporosis or spinal fractures; however, these maneuvers can flag pts
that would require earlier screening and raise the possibility of occult fractures.

Evidence:

21
Neurological Evaluation
Stroke
Is This Patient Having a Stroke?
Larry B. Goldstein; David L. Simel. JAMA 2005; 293: 2391-2402.

Physical Exam:
Arm Drift- limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or
45 degrees (if supine). Drift is scored if the arm falls before 10 seconds.

Clinical Results:
Increase the Probability of Stroke (+LR):
Presence of arm drift, acute facial paresis, and/or abnormal speech (5.5)

Decrease the Probability of Stroke (-LR):

Absence of all of arm drift, acute facial paresis, and abnormal speech (0.39)

*Neuroimaging is required to accurately discriminate between hemorrhagic and ischemic

*Mild increase (LR = 1.2) in early mortality with the existence of any combination of impaired consciousness,
hemiplegia, and conjugate gaze palsy
*Agreement between the examiners in the Dx of Stroke varies with sign/symptom and can be improved with
standardized scoring systems (ex. NIH stroke scale)

Bottom Line:
Focus on the three before mentioned signs will increase the accuracy of stroke Dx and using standardized
scoring systems (ex. NIHSS) will increase precision between examiners and better direct prognosis and
treatment. Even with the use of the clinical signs, appropriate neuroimaging are required to better define the
stroke subtype and any potentially treatable causes.

Evidence:

Clinical Rules:
*NIH Stroke Scale available at: http://www.strokecenter.org/trials/scales/nihss.html

ABCD score to determine occurrance of a stroke following a TIA:

• A (age; 1 point for age >60 years),
• B (blood pressure; 1 point for hypertension at the acute evaluation),
• C (clinical features; 2 points for focal weakness, 1 for speech disturbance without weakness), and
• D (symptom duration; 1 point for 10–59 minutes, 2 points for >60 minutes).
Total scores ranged from 0 (lowest risk) to 6 (highest risk). In a validation cohort of 378 patients with more recent TIAs, 7-day stroke risk
ranged from 0% in those with scores <4 to 35.5% in those with scores of 6; risk was intermediate with scores of 4 or 5. (Rothwell PM et al.
A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet 2005 Jul 2; 366:29-36.)

22
Myasthenia Gravis
Does This Patient Have Myasthenia Gravis?
Katalin Scherer; Richard S. Bedlack; David L. Simel. JAMA 2005; 293: 1906-1914.

Physical Exam:
-Curtain sign- pt stares straight ahead without blinking while the examiner holds the other eye lid open,
resulting in the free eye lid increasing in ptosis
-Lid twitch sign- pt follows the examiner from the looking down position to eye level, resulting in a brief
overshoot than ptosis of the eyelid
-Sleep test- pt left in dark room with eyes closed for 30 minutes
-Ice pack test- placement of a glove filled with crushed ice over a closed eye for 2 minutes
-Rest test- glove filled with cotton (placebo) over a closed eye for 2 minutes
-resolution of ptosis or >2mm improvement = +’ve result
-Cover-uncover test- to test for extra-ocular weakness, one eye is covered and the uncovered eye will drift
upward and/or lateral gaze
-Peek Sign- demonstrates orbicularis oculi fatigue by having the patients gently close their eyes and after
complete initial apposition of the lid margins, they separate within seconds, showing the white of the sclera
-Anticholinesterase Tests- edrophonium or pyridostigmine most commonly used, results in symptom
improvement

Clinical Results:
Increase the Probability of Myasthenia Gravis (+LR):
Peek sign (30), ice test (24), response to anticholinesterase meds (15), abnormal sleep tests (53) and prolonged
speech becoming unintelligible (4.5)

Decrease the Probability of Myasthenia Gravis (-LR):

Negative response to anticholinesterase meds (0.11)

Bottom Line:
Simple bedside tests, sign, and symptoms are valuable in the Dx.

Evidence:
Table 3. Clinical Signs and Symptoms and Results of Clinical Tests in the Prediction of MG
Sign/Symptom Positive LR (95% CI) Negative LR (95% CI)
Food in mouth after swallowing 13.0 (0.85-212.0) 0.70 (0.58-0.84)
Unintelligible Speech after prolonged speaking 4.5 (1.2-17.0) 0.61 (0.46-0.80)
Peek Sign 30.0 (3.2-278.0) 0.88 (0.76-1.0)
Quiver eye movements 4.1 (0.22-75.0) 0.82 (0.57-1.2)
Ice Test 24.0 (8.5-67.0) 0.16 (0.09-0.27)
Anticholinesterase Test 15.0 (7.5-31.0) 0.11 (0.06-0.21)
Rest Test 16.0 (0.98-261.0) 0.52 (0.29-0.95)
Sleep Test 53.0 (3.4-832.0) 0.01 (0.00-0.16)

23
Temporal Arteritis
Does This Patient Have Temporal Arteritis?
Gerald W. Smetana; Robert H. Shmerling. JAMA, Jan 2002; 287: 92 - 101.

Clinical Results:
Increase the Probability of Temporal Arteritis (+LR):
Hx of jaw claudication (4.2) or diplopia (3.4) and findings of artery beading (4.6), prominence (4.3) and
tenderness (2.6)

Decrease the Probability of Temporal Arteritis (-LR):

Absence of temporal artery abnormality (0.53) and normal ESR (0.2)

Bottom Line:
Only a few clinical findings and a normal ESR significantly change the LR of a positive biopsy. Thus, it is
clinician that must integrate the entire clinical picture to select the most likely pt for therapy and diagnosis.

Evidence:

24
Parkinson Disease
Does This Patient Have Parkinson Disease?
Goutham Rao; Laura Fisch; Sukanya Srinivasan; Frank D'Amico; Tadao Okada; Carolyn Eaton; Craig Robbins. JAMA 2003; 289:
347-353.

Clinical Results:
Increase the Probability of Parkinson’s Disease (+LR):
History of tremor (1.3-17), combination of rigidity and bradykinesia (4.5), loss of balance (1.6-6.6),
micrographia (2.8-5.9), shuffling gait (3.3-15), trouble with certain tasks such as turning in bed (13), opening
jars (6.1), and rising from a chair (1.9-5.2) and the glabellar tap test sign (4.5).

Decrease the Probability of Parkinson’s Disease (-LR):

History of combination of rigidity and bradykinesia (0.12), symptomatic tremor (0.24-0.60), loss of balance
(0.29-0.35), and trouble with opening jars (0.26) and glabellar sign (0.13)

Bottom Line: Multiple features of history are useful to increase the pretest probability of Parkinson’s, although
minimal signs have been proven.

Evidence:

25
Migraine
Does This Patient With Headache Have a Migraine or Need Neuroimaging?
Michael E. Detsky; Devon R. McDonald; Mark O. Baerlocher; George A. Tomlinson; Douglas C. McCrory; Christopher M.
Booth. JAMA, September 13, 2006; 296: 1274 - 1283.

Clinical Results:
Features that Increase the Likelihood of Migraine (+LR):
Containing four of five migraine features from the mnemonic POUNDing {Pulsating, duration of 4-72 hOurs,
Unilateral, Nausea, Disabling} (24), three of five features (3.5)

Features that Increase the Likelihood of Migraine versus Tension Headache (+LR):
Nausea (19), photophobia (5.8), phonophobia (5.2), exacerbation with physical activity (3.7)

Features that Decrease the Likelihood of Migraine versus Tension Headache (-LR):
Absence of Nausea (0.19), photophobia (0.24), phonophobia (0.38), exacerbation with physical activity (0.24)

Features that Increase the Likelihood that Neuroimaging is required (+LR):

Cluster-type headache (10.7), abnormal neurological examination (5.3), undefined headache (3.8), headache
with aura (3.2)

*No findings were strong enough to rule-out serious pathology

Bottom Line:
Migraine can be Dx with at least 4 of 5 historical features of POUNDing and differentiated from tension
headache with other features. Pts with features mentioned above should be imaged as they may be warning
signs of serious intracranial pathology.

Evidence:

Table 4. Pooled likelihood of significant abnormality on Neuroimaging

Clinical Feature Positive Likelihood Ratio Negative Likelihood Ratio

(95% CI) (95% CI)
Cluster-type headache 11 (2.2-52) 0.95 (0.84-1.1)
Abnormal Findings on Neurological 5.3 (2.4-12) 0.71 (0.60-0.85)
Examination
“Undefined” headache 3.8 (2.0-7.1) 0.66 (0.44-0.97)
Headache with Aura 3.2 (1.6-6.6) 0.51 (0.24-1.1)
Headache with Focal Symptoms 3.1 (0.37-25) 0.79 (0.51-1.2)
Headache Aggravated by Exertion or 2.3 (1.4-3.8) 0.70 (0.56-0.88)
Valsalva
Headache with Vomiting 1.8 (1.2-2.6) 0.47 (0.29-0.76)
Worsening Headache 1.6 (0.23-10) 1.0 (0.78-1.2)
Male Sex 1.3 (0.89-1.8) 0.86 (0.68-1.1)
Quick-onset Headache 1.3 (0.33-5.1) 0.79 (0.14-4.4)
New-onset Headache 1.2 (0.74-2.0) 0.89 (0.63-1.3)
Headache with Nausea 1.1 (0.87-1.3) 0.86 (0.63-1.2)
Increased Headache Severity 0.83 (0.54-1.3) 1.2 (0.91-1.4)
Migraine-type Headache 0.55 (0.28-1.1) 1.2 (0.84-1.7)

26
Vertigo
Does this dizzy patient have a serious form of vertigo?
David A. Froehling, Marc D. Silverstein, David N Mohr, Charles W. Beatty. JAMA. 271(5):385-8, 1994 Feb 2.

Physical Examination:
Dix-Hallpike Manuever: begin with patient sitting with eye’s fixed on examiners forhead. Firmy graph
patient’s head and have them quickly lie supine with head turned about 30° to one side and 30° below the
examining table – observe for nastagmus. Repeat with head tilt to opposite side.

Clinical Results:
-Combination of a positive head-hanging maneuver plus either vertigo or vomiting has a high likelihood (LR =
7.6) of being peripheral vertigo.

Carpal Tunnel Syndrome

Does this patient have Carpal Tunnel Syndrome?
Christopher A. D’Arey and Steven McGee JAMA. 283(23):3110-7, 2000 Jun 21.

Physical exam:
Katz Hand Diagrams:
Classic Pattern Probable Pattern Unlikely Pattern

Tinel Sign: paresthesias in median nerve distribution when clinician taps on distal wrist crease over median
nerve
Phalen Sign: paresthesias in median nerve distribution when patient flexes both wrists at 90° for 60sec
Flick Sign: Patient demonstrates flicking motion of hand (similar to shaking a thermometer) as response to
question “what do you do with your hands when the symptoms are the worst?”
Square Wrist Sign: ratio of anteroposterior dimension of wrist to mediolateral dimension > 0.70 when
measured at distal wrist crease
Closed first Sign: paresthesias in median nerve distribution when patient flexes fingers in closed fist for 60sec
Pressure Provacation: paresthesias in median nerve distribution when examiner presses palmar aspect of
patients wrist with their thumb for 60sec

27
Tourniquet Test: paresthesias in median nerve distribution when blood pressure cuff is inflated around
patient’s arm for 60sec.
Clinical Results:
Increased probability of CTS
Findings favoring electrodiagnosis of CTS were hypalgesia (decreased sensitivity to pain) in median territory
(+LR 3.1), classic of probable Katz hand diagram results (+LR 2.4) and weak thumb abduction (+LR 1.8)

*Flick sign, closed fist sign and square sign show promise but require additional studies

Decreased probability of CTS

Findings arguing against electrodiagnosis of CTS were Katz hand diagrams classified as unlikely (LR 0.2) and
normal thumb abduction strength (LR 0.5)

Bottom Line:
The following findings had no value in diagnosis of CTS: Tinel’s sign and Phalen’s sign., patient’s age,
presence of nocturnal or bilateral symptoms, thenar atrophy, pressure provocation test, and the tourniquet test.

Evidence:
Table 1 – Diagnostic Accuracy of History / Physical Examination for CTS
Finding Positive LR Negative LR
Closed fist Sign 7.3 (1.1-49.1) 0.4 (0.2-0.7)
Hypalgesia 3.1 (2.0-5.1) 0.7 (0.5-1.1)
Flick Sign 21.4 (10.8-42.1) 0.1 (0.0-0.1)
Square Wrist Sign 2.7 (2.2-3.4) 0.5 (0.4-0.8)
Classic or Probable Katz Hand Diagram 2.4 (1.6-3.5) 0.5 (0.3-0.7)
Thenar atrophy 2.2 (0.7-6.7) 0.7 (0.5-1.1)
Weak thumb abduction 1.8 (1.4-2.3) 0.5 (0.4-0.7)
Tinel Sign 1.4 (1.0-1.9) 0.8 (0.6-1.1)
Phalen Sign 1.3 (1.1-1.6) 0.7 (0.6-0.9)
Nocturnal paresthesia 1.2 (1.0-1.4) 0.7 (0.5-0.9)
Pressure Prevocation 1.0 (0.8-1.3) 1.0 (0.9-1.1)
Tourniquet Sign 1.0 (0.5-1.9) 1.0 (0.7-1.5)

28
Infectious Disease Evaluation
Acute Meningitis
Does this adult patient have acute meningitis?
John Attia, Rose Hatala, Deborah J. Cook, Jeffery C. Wong JAMA. 282(2):175-81, 1999 Jul 14.

Physical Examination:
Nuchal Rigidity: rigidity on gentle forward flexion of neck of supine patient.
Kernig’s Sign: with patient positioned supine with hip flexed 90°, extension of knee joint elicits either stiffness
or pain in the lower back or thigh.
Brudzinski’s Sign: passive flexion of the neck of supine patient results in flexion of the hip and knee joints.

Clinical Results
Ruling in meningitis:
-Kernigs and Brudzinski are useful for ruling in meningitis if positive (specificity 100%), but not very useful for
ruling out meningitis if not present (sensitivity 9%)

Ruling out meningitis:

Absence of all 3 classic signs (fever, neck stiffness and altered mental status) makes diagnosis of meningitis
extremely unlikely
-Absence of fever (sensitivity 85%) is the strongest physical sign for ruling out meningitis with absence of neck
stiffness (sensitivity 70%) or altered mental status (sensitivity 67%) also being useful.

Bottom Line:
Diagnosis of meningitis is virtually eliminated in the absence of any of the three classic features of fever, neck
stiffness or altered mental status (sensitivity 99%), and very unlikely if patient does not have at least two of
these features (sensitivity 95%).

Evidence:

29
How Do I Perform a Lumbar Puncture and Analyze the Results to Diagnose Bacterial Meningitis?
Sharon E. Straus; Kevin E. Thorpe; Jayna Holroyd-Leduc. JAMA 2006; 296: 2012-2022.

Clinical Results:
-Atraumatic versus standard needle and early mobilization did not show a significant decrease headache
-Reinsertion of stylet prior to needle withdrawal decreased headache
-Most accurate laboratory values to rule in bacterial meningitis is a CSF-blood glucose ratio of 0.4 or less (18),
WBC in CSF over 500/mcL (15), and CSF lactate of 3.5 mmol/L or more (21).

Bottom Line:
Focus on the before mentioned CSF values of Dx of bacterial meningitis. Bed rest after LP is not of use,
atraumatic needles may decrease headaches, and reinsertion of the stylet should be done on needle withdrawal.

Evidence:

Influenza
Does This Patient Have Influenza?
Stephanie A. Call; Mark A. Vollenweider; Carlton A. Hornung; David L. Simel; W. Paul McKinney. JAMA 2005; 293: 987-997.

Clinical Results:
-Age is essential for using clinical findings to influence the chance of a correct Dx.

Increase the Probability of Influenza (+LR):

*Decrease the LR: absence of cough (0.42), fever (0.4), nasal congestion (0.49) and presence of sneezing (0.49, if
>60 yo)

Decrease the Probability of Influenza (-LR):

*Increase the LR if over 60: fever, cough, and acute onset (5.4), fever and cough (5.0), and fever alone (3.8),
malaise (2.6), and chills (2.6)

Bottom Line:
Clinical findings are not accurate at identifying influenza and should be used in conjunction with
epidemiological evidence to enhance Dx accuracy then treat empirically or with the confirmation of the rapid
influenza test.

30
Urinary Tract Infection
Does This Woman Have an Acute Uncomplicated Urinary Tract Infection?
Stephen Bent; Brahmajee K. Nallamothu; David L. Simel; Stephan D. Fihn; Sanjay Saint . JAMA, May 2002; 287: 2701 – 2710.

Clinical Results:
Increase the Probability of UTI (+LR):
Dysuria (1.5), frequency (1.8), hematuria (2.0), CVA tenderness (1.7), back pain (1.6), combinations of dysuria
and frequency, but no vaginal discharge or irritation (24.6), self diagnosis of recurrent UTIs (4.0)

Decrease the Probability of UTI (-LR):

Absence of back pain (0.8) or dysuria (0.5), hx of vaginal discharge (0.3) or vaginal irritation (0.2), and vaginal
discharge on PE (0.7)

Bottom Line:
A pt presenting with one or more urinary symptoms has a 50% probability of the Dx and when used in specific
combinations, history can effectively rule-in the Dx; however, if symptoms are present, Hx, PE, and urinalysis
cannot rule-out the Dx.

Evidence:
Table 2. Clinical Signs and Symptoms in the Prediction of Urinary Tract Infection
Symptom/Sign Positive LR (95% CI) Negative LR (95% CI)
Dysuria 1.5 (1.2-2.0) 0.5 (0.3-0.7)
Frequency 1.8 (1.1-3.0) 0.6 (0.4-1.0)
Hematuria 2.0 (1.3-2.9) 0.9 (0.9-1.0)
Fever 1.6 (1.0-2.6) 0.9 (0.9-1.0)
Flank Pain 1.1 (0.9-1.4) 0.9 (0.8-1.1)
Lower Abdominal Pain 1.1 (0.9-1.4) 0.9 (0.8-1.1)
Vaginal Discharge 0.3 (0.1-0.9) 3.1 (1.0-9.3)
Vaginal Irritation 0.2 (0.1-0.9) 2.7 (0.9-8.5)
Back Pain 1.6 (1.2-2.1) 0.8 (0.7-0.9)
Self-Diagnosis 4.0 (2.9-5.5) 0.0 (0.0-0.1)
Vaginal Discharge on PE 0.7 (0.5-0.9) 1.1 (1.0-1.2)
CVA tenderness on PE 1.7 (1.1-2.5) 0.9 (0.8-1.0)
Dipstick Urinalysis 4.2 0.3
(positive= +nitrite and leuks,
negative= -nitrites and leuks)

31
Septic Arthritis
Does This Adult Patient Have Septic Arthritis?
Mary E. Margaretten; Jeffrey Kohlwes; Dan Moore; Stephen Bent. JAMA, April 4, 2007; 297: 1478 - 1488.

Clinical Results:
*Risk Factors: age, DM, RA, joint Sx, hip or knee prosthesis, skin infection, HIV (85% Sensitivity)
*Most Sensitive Clinical Findings: Joint Pain (85%), hx joint swelling (78%), fever (57%)

Increase the Likelihood of Septic Arthritis (+LR):

Increase with WBC count ( >25 000, LR 2.9, > 50 000 LR 7.7, >100 000, LR 28.0), % PMN >90% (3.4), the
presence of joint prosthesis and skin infection (15.0), recent joint injury (6.9)

Decrease the Likelihood of Septic Arthritis (-LR):

PMN<90% (0.34), normal ESR (0.17), normal peripheral WBC (0.28)

Bottom Line:
Limited studies have been performed on clinical signs and symptoms, but it appears that clinical examination
can identify the individuals that may have a septic joint (ie recent trauma or prosthetic joint and overlying skin
infection). Arthrocentesis is essential to predict an accurate likelihood prior to gram stain and culture results.

Evidence:

Table 4 + 5. Summary of Test Characteristics of Synovial Fluid Studies

Sensitivity Specificity Positive LR Negative LR
WBCs >100 000/µL 29 99 28.0 (12.0-66.0) 0.71 (0.64-0.79)
WBCs >50 000/µL 62 92 7.7 (5.7-11.0) 0.42 (0.34-0.51)
WBCs >25 000/µL 77 73 2.9 (2.5-3.4) 0.32 (0.23-0.43)
Polymorphonuclear cells ≥90% 73 79 3.4 (2.8-4.2) 0.34 (0.25-0.47)
Low glucose* 51 85 3.4 (2.2-5.1) 0.58 (0.44-0.76)
Protein >3.0 g/dL 48 46 0.90 (0.61-1.30) 1.10 (0.76-1.60)
LDH >250 U/L 100 51 1.9 (1.5-2.5) 0.10 (0.00-1.60)
Abbreviations: CI, confidence interval; LDH, lactate dehydrogenase.
*Defined in the different studies as serum/synovial fluid glucose ratio of less than 0.5 or 0.75, synovial fluid glucose level of
less than 1.5 mmol/mL, or both. To convert synovial fluid glucose to g/dL, divide by 0.0555.

32
Sinusitis
Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination
John W. Williams Jr., David L. Simel JAMA. 270(10):1242-6, 1993 Sep 8.

Clinical Results:
-The independent predictors for sinusitis are maxillary toothache, poor response to nasal decongestants, abnormal transillumination and
coloured discharge.
-When found alone are neither sensitive nor specific for sinusitis – they must be combined to have any predictive value.

Bottom Line: *Combination of all independent predictors mentioned above increases the likelihood of sinusitis sharply (LR=6.4), while
having none of these predictors or only one in isolation virtually rules out sinusitis.
Evidence:

33
General Patient Safety Evaluation
Depression
Is This Patient Clinically Depressed?
John W. Williams Jr; Polly Hitchcock Noël; Jeffrey A. Cordes; Gilbert Ramirez; Michael Pignone . JAMA, Mar 2002; 287: 1160 - 1170.

Clinical Rules:
-numerous studies of 1 to 5 minute screening tests had average PLR 3.3 and 0.19 NLR
-no significant difference between tools
-high agreement in Dx of major depression between psychiatrists and Family Physicians

Bottom Line:
Questionnaires are a reasonable starting point, but diagnostic confirmation by mental health professionals or
family physicians should be done.

Patient Falls
Will My Patient Fall?
David A. Ganz; Yeran Bao; Paul G. Shekelle; Laurence Z. Rubenstein. JAMA, January 3, 2007; 297: 77 - 86.

Clinical Results:
-Baseline Pretest for age>65 27%
-Highest LRs: fall in past year (2.3-2.8) and detectable gait abnormalities (1.7—2.4)
-No consistent effect: visual impairment, medication variables, decreased ADLs, impaired cognition, and
orthostatic hypotension

Bottom Line:
Patients with gait abnormalities or Hx of falls in the past year are at increased likelihood of falling in the future.

Alcohol Abuse
Does this patient have an alcohol problem?
James M. Kitchens, JAMA. 272(22):1782-7, 1994 Dec 14.

Cage Questionnaire
1. Have you ever felt you needed to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about drinking?
4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of
a hangover?

Clinical Results:
Ruling in EtOH abuse
Scores of 3 or 4 have very high likelihood of alcoholism

Ruling out EtOH abuse

Score of 0 has a very high predictive value for ruling out alcoholism.

Evidence:

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Additional Evaluation
Breast Cancer
Does this patient have breast cancer? The screening clinical breast examination: should it be done?
Mary B. Barton, Russell Harris, Suzanne W. Fletcher JAMA. 282(13):1270-80, 1999 Oct 6.

Bottom Line:
Increased probability of Breast Ca
-The following positive findings on clinical breast examination increase the likelihood of breast cancer: fixed
mass, hard mass, irregular mass and mass size >2cm.
-A well-conducted clinical breast exam can detect up to 50% of asymptomatic breast cancers, and a positive
exam can significantly increase the probability of breast cancer (+LR 10.6)

Decreased Probability of Breast Ca

-Negative CBE’s should be viewed with caution and additional screening modalities should be utilized in ruling
out breast cancer.
Table 1: Accuracy of various CBE physical findings:
CBE Finding Positive LR
Mass 2.1
Fixed 2.4
Hard 1.6
Irregular 1.8
>2cm Lump 1.9

Table 2: Accuracy of the CBE to diagnose breast cancer

Positive LR Negative LR Sensitivity % Specificity %
Pooled Results 10.6 (5.8-19.2) 0.47 (0.40-0.56) 54.1 94

Thyroid Goiter
Does this patient have a Goiter?
Kerry Siminoski. JAMA. 273(10):813-7, 1995 Mar 8

Physical Exam:
-normal thyroid is <20g

Clinical Results:
Increased Probability of Goiter
-clinical assessment of a thyroid gland as > 2x normal (>40g) is extremely predictive of a goiter being present
(+LR 25)
-Inspection of lateral prominence >2mm is highly predictive of a goiter being present

Decreased Probability of Goiter

-Gland that is not visible with extension of neck virtually rules out a goiter (+LR 0)

Accuracy of Assessing Thyroid Gland Weight Accuracy of Lateral Prominence in assessing Goiter

Thyroid Size Positive LR Size (Lateral Prominence) Positive LR

Normal, 0-20g 0.15 (0.10-0.21) not visible 0.41 (0.34-0.49)
1-2x Normal 20-40g 1.9 (1.1-3) 0-2mm 3.4 (1.8-6.3)
>2x Normal >40g 25 (3.6-175) 2-10mm Infinity
>10mm Infinity

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Clubbing
Does This Patient Have Clubbing?
Kathryn A. Myers; Donald R. E. Farquhar. JAMA, Jul 2001; 286: 341 - 347.

Definition:
Clubbing- proliferation of connective tissue between the nail matrix and distal phalanx that results in
symmetrical or asymmetrical enlargement of fingers and/or toes +/- associated with hypertrophic
osteoarthropathy

Physical Exam:
Schamroth Sign- loss of the diamond window that is normally produced when the dorsal surfaces of terminal
phalanges are opposed
Profile sign and Hyponychial angle (See Below)
Phalangeal Depth Ratio- ratio of the distal phalangeal finger depth/ interphalangeal finger depth. Normal < 1.

DPD = distal phalangeal depth, IPD = interphalangeal depth.

(Green et al . Introduction to Clinical Medicine. B.C. Decker Inc. Philadelphia)

Clinical Results:
-Profile angle (> 176°), hyponychial angle (>192°), and phalangeal depth ratio (>1.0 or >1.05 in COPD
patients) suggest the presence of clubbing
-No objective diagnostic criterion has been created to assess clubbing.
-Schamroth sign has not been formally evaluated.
-Interobserver agreement about the presence of clubbing is only fair to moderate

Bottom Line:
In the absence of strong evidence based definition of clubbing and the poor precision of the diagnosis, the above
mentioned methods and values can be used to aid in the diagnosis. If the diagnosis is made, no established
optimal strategy of investigation exists, so the clinician must decide on the best course of investigation.

Melanoma
Does this patient have a mole or a melanoma?
John D. Whited, James M. Crichnik JAMA. 279(9):696-701, 1998 Mar 4.

Physical exam:
ABCD(E) criteria: Asymmetry, Border irregularity, Color irregularity, Diameter >6mm, Elevation

Clinical Results:
Decreased probability of melanoma
-absence of all ABCD criteria virtually ruled out melanoma (-LR 0, Sens 92-100)

Increased probability of melanoma

-presence of border irregularity, color irregularity and diameter >6mm in combination was extremely predictive
of melanoma (+LR 62, spec 98.4)

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Evidence:

Patient History
Does This Patient Have a Family History of Cancer?: An Evidence-Based Analysis of the Accuracy of Family Cancer History
Harvey J. Murff; David R. Spigel; Sapna Syngal. JAMA, September 22/29, 2004; 292: 1480 - 1489.

Clinical Results:
Findings that Increase the Likelihood of a Family Cancer History (+LR):
-Pts with Cancer that report a family history of one of the five types of cancer shown below are likely to be
accurate, however, Prostate and Endometrial Ca have wide Confidence Intervals that are below 5.
-Pts without a history of cancer that report a family history of the five types of cancer shown below are also
likely to be accurate although the +LRs are reduced from Pts with Ca.

Findings that Decrease the Likelihood of a Family Cancer History (-LR):

-Pts with Cancer that deny Colon Ca (0.29), Prostate Ca (0.25), Breast Ca (0.07), and Ovarian (0.21) are
accurate.
-Pts without a history of Ca have less accuracy in knowing the absence of Ca in first-
degree relatives compared to Pts with Cancer with Breast being the most accurate
(0.20)

Bottom Line:
Positive family histories for Ca in first-degree relatives are overall accurate, but
negative family histories are not as reliable. Patients with Ca tend to be more accurate.
FHx of Colon and breast Ca are the most reliable.

Evidence:
Table 1. Patient Report of a Family History of Cancer in a Table 2. Patient Report of a Family History of Cancer in a
First-Degree Relative in Individuals With Cancer First-Degree Relative in Individuals Without Cancer
Cancer Type Positive LR Negative LR Cancer Type Positive LR Negative LR
(95% CI) (95% CI) (95% CI) (95% CI)
Colon 23.0 (8.1-64.0) 0.29 (0.13-0.67) 23.0 (6.4-81.0) 0.25 (0.10-0.63)
Colon
Prostate 24.0 (2.3-262.0) 0.25 (0.16-0.39) 12.3 (6.5-24.0) 0.32 (0.18-0.55)
Prostate
Breast 41 (23-75) 0.07 (0.03-0.13) 8.9 (5.4-15.0) 0.20 (0.08-0.49)
Breast
Endometrial 20.0 (4.3-89.0) 0.55 (0.35-0.86) 14.0 (2.2-83.4) 0.68 (0.31-1.52)
Endometrial
Ovarian 44 (15-132) 0.21 (0.12-0.37) 34.0 (5.7-202.0) 0.51 (0.13-2.10)
Ovarian

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Penicillin Allergy
Is This Patient Allergic to Penicillin?: An Evidence-Based Analysis of the Likelihood of Penicillin Allergy
Alan R. Salkind; Paul G. Cuddy; John W. Foxworth. JAMA, May 2001; 285: 2498 - 2505.

Clinical Results:
Only 10-20% of Patients that report a penicillin allergy have a true Type I allergic reaction to penicillin.
The +LR of a patient that claims an allergy is 1.9.
The –LR of a patient that claims an allergy is 0.5.

Bottom Line:
With the majority of patients making incorrect assumptions to what is a “true” allergy, a detailed history (ie
Type 1 signs/symptoms of Anaphylaxis and/or hypotension, laryngeal edema, wheezing, angioedema, urticaria
within a short time of consuming the drug) can allow physicians to exclude the allergy. A skin test should be
done if there is a concern and the Abx is required.

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