From the article
SOFA score: CNS, Cardio, Respi, Liver (Bilirubin), Renal (Creatinine), Coagulation (Platelets)
Reference: SInger et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810
- Saying “ninety-nine” while palpating the chest wall
- More prominent in men due to lower pitched voices.
- ONLY ASYMMETRICAL FINDING IS SIGNIFICANT.
- Topographical: used to delineate border of heart, liver and diaphragmatic excursions.
- Pleural effusion: stethoscope is placed below 12th rib. Percussion is done from posterior chest from apex to base.
– At some point, the dull sound will change to a clearer one as it approaches the stethoscope. If this happens above 12th rib, it indicates pleural effusion.
- Another version is by listening over the back of chest while tapping over the manubrium.
– Clinician should hear identical sounds in two sides of chest. A decreased intensity indicates ipsilateral disease on that side
– Special types of resonance: Skodaic’s, amphoric
- Resonance heard above the pleural effusion.
- Why? Nobody knows
- Flicking the tense cheek while holding the mouth open mimics the sound
- Indicates presence of cavities.
- A small triangle of dullness at posterior chest contralateral to side of effusion
- Narrow area of resonance between the dullness of neck and shoulder muscles.
- If this resonance is lost, it indicates apical lung diseases.
- Topographic percussion theory
– The characteristics of the underlying organs determine the type of the sounds heard.
- Cage resonance theory (the chest wall is the cage, and how it resonates affects the percussion)
– The type of sounds are also affected by the chest wall and the strength of the stroke.
Cage resonance theory maybe more accurate:
- External pressure on the chest dampens the percussion notes.
- Liver span is SMALLER when percussing with stronger stroke.
– Stronger stroke produces more vibrations and therefore more resonance.
– If according to topographic percussion theory (stronger strokes lead to deeper penetration), the liver span should have been larger.
- Possibly sound transmission circumferentially in chest wall rather than through the lungs
– Heart is not detected. If the sound is transmitted through the lung, some dullness should have been heard in left side of the chest
– Sounds intensity changes during Valsava maneuver which tenses the chest wall.
– Sound intensity recorded when the patient breathes room air and a mixture of oxygen and helium is the same (different gases should have different density and this affects the sound intensity).
So what’s good?
- Only asymmetrical dullness/hyperresonance using comparative percussion maybe ok to detect pulmonary pathologies.
- Auscultatory percussion is also very specific for detecting pleural effusion.
Evidence Based Physical Diagnosis. Steven McGee.
Anatomy of thyroid
- Landmarks: laryngeal prominence (adam’s apple) of thyroid cartilage and cricoid cartilage which lies below it
- Isthmus of thyroid normally lies just below the cricoid cartilage
- High vs low lying thyroid
– If distance between laryngeal prominence and the suprasternal notch is far (eg 10cm), the thyroid gland maybe high lying (pseudogoiter)
– If laryngeal prominence is close to suprasternal notch (<5cm), the thyroid gland is low lying (and located retrosternally). Palpation maybe impossible.
Inspection of thyroid gland
- See from the side. The line between cricoid prominence and suprasternal notch (where the thyroid gland is located) is a straight line.
- If it is bowed, consider goiter
- An easier way to palpate thyroid gland
What do we palpate?
- Consistency (hard or soft)
The key to know that what we palpate is thyroid gland is
- It moves during swallowing, and then hesitate a while before returning. As thyroid gland and tracheal is connected by ligaments.
- If it does not move during sallowing or does not hesitate before returning to its original position, it is likely not thyroid gland.
Estimation of size
- Rule of thumb: lateral lobe is enlarged if it is larger than distal phalanx of the patient’s thumb
- WHO grading
- May cause TOS, SVC syndrome and compression of trachea and esophagus
- TOS (thoracic outlet syndrome):
– Compression of brachial plexus: pain in the multiple myotomes in UE
– Compression of subclavian vein: UE venous thrombosis (Paget-Schroetter syndrome)
- SVC syndrome: elevated JVP + plethora + facial & arm edema
- Compression of trachea and esophagus: dyspnea, stridor, dysphagia
- Cystic swellings of thyroglossal duct , an epithelium lined remnant marking the descent of thyroid tissue from the base of tongue to its final location
- Midline neck mass
- Characteristic sign is upward movement when the patient protrudes the tongue
- Prelaryngeal lymph node
- Named Delphian because it is the first one exposed during surgery and its appearance often foretells what the surgeon will find in thyroid.
- Radiologically, it is situated in lymph node level VI
- If it’s palpable, it is usually enlarged – suspect malignancy or Hashimoto’s thyroidits
- Classical triad of puffy skin + delayed reflexes + thick & nasal speech
– Skin: dry, cold, puffy skin
– Achlles reflex: delayed reflex due to prolonged contraction & relaxation
– Hypothyroid speech: slow, deep and nasal (as if patient has a cold)
- Billewicz Diagnostic Index for hypothyroidism
>30 has a high likelihood of hypothyroidism
- Triad of prominent eyes + goiter + tachycardia
- Auscultation in thyroid gland can often ellicit bruit (in 70% of patents)
- Eye findings:
Lid lag: von Graefe sign
– ask patient to look down, the upper eyelid “lags” behind
Lid retraction: Dalrymple’s sign
– ask patient to look straight, white sclera is seen between the limbus and the lid margin; usually the lid margin rests just below the corneal limbus
– NO SPECS
– Consider if patient with Graves disease complain of gritty sensation in the eyes or diplopia
- CV findings:
– Loud S1
– Means Lerman scratch (systolic rub resembling scratching near the left 2nd ICS)
- Skin findings:
– Moist (due to increased sweating) and warm
– Pretibial myxoedema
- Neuromuscular findings
– Fatigue & weakness
– Fine tremor due to sympathetic overflow
– Brisk ankle reflexes
** Other ddx of lid retraction
- Facial palsy: unilateral weakness of orbicularis oculi –> levator palpebrae is no longer being opposed
- Unilateral ptosis: attempts to elevate the weakened lid causes excessive neural signals which end up elevating another lid
- Previous eyelid surgeru
Von Graefe: lid lag (We look down in Grief !)
Darylrmple sign: lid retraction (DaryLRmple)
Joffroy sign: lack of forehead wrinkling (FF resembling wrinkling)
Stellwag sign: staring look (Stellwag for Staring)
Moebius sign: Poor convergence (Merging Of EyeBalls Is UnSuccessful)
Wayne Diagnostic Index for hyperthyroidism >20 points have a high likelihood for hyperthyroidism
Note: BOTH hypo and hyperthyroidism cause amenorrhea !
- Hypothyroidism: increased TRH causes increased prolactin production which blocks GnRH
- Hyperthyroidis: multiple mechanisms, but likely linked to high SHBG which leads to high ratio of bound estradiol. Only free estradiol can induce a LH peak.
Mnemonic for THYROID disorders: NEVER FORGET THEM AGAIN !
- Tremor (in hyper)
- Heart Rate
- Yawn (fatigue in both)
- Reflexes (brisk or delayed)
- Intolerance to temperature (heat or cold)
- Diarrhea (or constipation)
- Increased or decreased appetitie
- Skin (cool,dry and puffy or moist and warm skin)
- Myxoedema (facial puffiness in hypothyroidism, pretibial myxoedema)
Steven McGee. Evidence Based Physical Diagnosis. Pg 250-276
Note: there is a drug not mentioned in this list
- Mentioned in NICE 2009 guideline for T2DM but not in 2015.
- Insulin secretagogue, especially increases its secretion in response to glucose (first phase insulin release).
– Used in patients with unpredictable meal time.
– Good to tackle postprandial hyperglycemia (mild increase in fasting glucose level but disproportionately high A1C)
- Short duration of action (achieves peak plasma level in 1 hr & producing a rapid insulin-releasing effect that lasts for 3 hrs ) and hepatically excreted (T1/2 = 1 hr)
– Can be used in renally-impaired patients
– Lesser hypoglycemia (as it is short acting and increases insulin secretion IN RESPONSE to glucose, unlike sulfonylureas)
Rational of combination therapy
- NICE suggests metformin + sulfonylurea or pioglitazone or DPP4i
- Common threshold to initiate combination therapy is when A1C >8%.
- With time, not only insulin resistance, there is loss of B-cell function as well (to abou 25% in 6 years).
- Primary objective is to tackle the problems of insulin resistance + deficiency.
– Metformin: insulin sensitizer
– Pioglitazone: insulin sensitizer
– Sulfonylurea: insulin secretagogue
– DPP4i: GLP-1 based (increases insulin secretion)
Nodular lymphangitis is characterized by inflammatory nodules along the lymphatics draining a primary skin infection.
Reference: DiNubile MJ. Nodular lymphangitis: a distinctive clinical entity with finite etiologies. Curr Infect Dis Rep. 2008 Sep;10(5):404-10
- Lateralization in Weber test
– Sensorineural loss: to good ear (= CONTRALATERAL ear is damaged)
– Conductive loss: to bad ear (= IPSILATERAL ear is damaged)
- Rinne test
– BC>AC in conductive loss
– AC>BC in sensorineural loss
Steven McGee. Evidence Based Physical Diagnosis. Pg 242-249