Shoulder Exam

Last week I did a presentation at the HOME project on the shoulder exam with a few clinical cases I saw in clinic. It was a smashing success -- everyone seemed to appreciate an introduction/review of some of the maneuvers!

One of the toughest parts of the physical exam is remembering all of the routine shoulder maneuvers.

Here's a few mnemonics I shared that I use to help myself remember things:

Arm Movements

• Flexion of the arm = Forward to the Face
• Internal Rotation of the arm = In handcuffs
• (alternatively, External Rotation = Execution of Ex-Convict)
• ADduction of the arm = ADDing to the midline
• Scarf sign = toss a scarf around opposite shoulder

Forearm Movements

• Supination = Holding a Bowl of "Soup"
• Pronation = Putting away Palm

Special Maneuvers

• Range of Motion (and Impingement Signs)
• Neer = arm "Near" to the ear
• Hawkins = flap like a "Hawk"
• Apley scratch test = Applying Suntan lotion to back
• Rotator Cuff Tears
• Supraspinatus
• Jobe's Empty Can (duh!)
• Hornblower's (ditto!)
• Biceps
• Speed's = speedin' down the highway
• Labral Tear
• O'Brian = *Irish accent*
  What, so O'Brien gets the thumbs down, but Leno gets a thumbs awp?  I'm cryin' heah!!
• Subscapularis
• Gerber's lift off = wiping baby food off the back (okay, its a stretch, but you can't win 'em all!)

 

That's not my second opinion! :)

Pre-op "clearance"

Physicians often receive requests from surgeons for a pre-op physical to "clear the patient for surgery."

What this "clearance" entails is not entirely clear.

Surgeons are worried that an unknown medical problem will rear its ugly head during the surgery and bite them in the butt... or the anesthesiologist will call off the surgery because of blood pressure concerns.

 

Consults are often made to a cardiologist with the intent of doing a pre-op EKG/Echo + stress test to determine if the patient is fit for surgery at the surgeon's behest.  What is important to understand is that another physician is often the one responsible for keeping the patient alive during the surgery and it is this person, who is most interested in the pre-operative assessment.

Unfortunately, the anesthesiologist often just turns out to be the doctor who happens to be in the OR on that particular day and has not established any sort of relationship with the patient beyond their initial bedside assessment in the waiting room.

In the Cleveland Clinic Journal of Medicine, two anasthesiologists tackle this issue and give some general advice for pre-op consults.

Consults that provide pertinent quantitative data about the patient are helpful—eg, the heart rate at which ischemia was exhibited during stress testing and the degree of ischemia.

Anesthesiologists do not need assistance with managing intravenous drugs (with the exception of unusual agents), but they can use specific guidance on managing oral medications pre- and postoperatively to best achieve optimization and steady-state concentrations.

Pertinent recent information (< 5 years old) from the nonanesthesiology literature should be provided.

Medical consultants should arrange for follow-up care for patients with active conditions not addressed by the surgery.

Absolute recommendations should be avoided in a consult: the surgical team may have good reason not to follow them, and legal repercussions could ensue. The words “consider” or “strongly consider” usually suffice, except where there is an absolute standard of care.

Specific questions to answer include such things like assessment of cardiac function (hx of angina, last echo results, exercise tolerance,) successful blood pressure and diabetic regimens, etc.

 

References

Giving Anaesthesiologists What They Want: How to Write a Useful Preoperative Consult.  CCJM 11/2009

Rheum Case 1

A 55 year old Caucasian male presented to a neighbor island ED with lower extremity skin rash, swelling and severe arthritis following a sore throat.

History of Present Illness:  Pt had an itchy and sore throat for which he was treated with azithromycin.  He sought out new antibiotics after 5 days without relief.  Approximately ten days after the onset of the sore throat, he went to bed complaining of a "sore wrist."  Upon awakening the following morning, he felt severe pain in both wrists with progressive immobility of the left wrist.  His skin broke out with a rash later on in the day on his hands, wrists and ankles.  His legs started swelling and he had difficulty walking.

Denied red eyes or pain with urination.

Past medical history: significant for migratory arthritis, Crohn's disease, HLA-B27(+).  Patient has a long history of severe anaphylactic/eczemal allergic reactions as well.

 

Pertinent physical exam:

Skin exam revealed multiple, progressive, round tender "palpable purpuric" lesions on the hands and ankles.

4+ pitting edema was present in the lower extremities.

 

Diagnosis: enteropathic arthritis and erythema nodosum most likely secondary to a streptococcal infection of the throat with subsequent reaction *HLA-B27(+)

Differential:
Reiter's/Reactive arthritis triad: conjunctivitis, arthritis, urethritis (Can't see, can't pee, can't climb a tree)

Course: Dermatology, ID, and rheumatology consultations were made.  Pt was reluctant to start a course of steroids in the ED, given a past history of steroid-associated insomnia and psychosis.  After 5 days of worsening edema and tender arthritis, he agreed to a steroid burst of 40mg daily and tapering regimen with rheumatology to follow.

 

References

eMedicine: Erythema Nodosum

eMedicine: Enteropathy arthritides

Learning Radiology: An Approach to Arthritis

I love my Kindle!

I always wanted some "electronic paper" device that I could take notes on and hold all of the files I wanted at my fingertips ...

My parents gave me the Kindle DX as a birthday gift!  It has "whispernet" dedicated wireless for simple bookdownloading/wikipedia browsing (battery life 2 days) and a solid read time of 2 weeks with the internet disabled.  Since it doesn't have a backlight and it only draws power when the pages turn, it's a great device for travel.

It feels almost blasphemous to admit how I am fond of my iPhone, especially now that the iPad has come out as the sexy attractive alternative to this eReader.  Amazon will hopefully step up its game and work harder with the Kindle.  In any case, I think that the Kindle was/IS still a good buy.

For my MD preparations, I bought a series of clinical books:

• DeGowin's Diagnostic Exam
• Good reference, a bit thorough but a fun read nonetheless with great quotables!
  
• The Rational Clinical Examination by JAMA
• Great analysis for an evidence-based H&P!
  
• ECG Diagnosis Made Easy
• Image quality can be an issue on a grayscale e-Ink pad.  Keep that in mind when purchasing eBooks.
  
• First Aid for the Family Medicine Boards
• Hopefully this will pay off in spades over the next 3-4 years during my residency!

Then, I uploaded the AFP pdf series on assorted Family Medicine topics (we received a CD with copies of some important articles published in the past 10 years in our third year rotation.)

Additionally, I have been tossing in pdfs along the way, for ICU topics mainly.

There are tons of free e-books to read as well.  I've read half of the Sherlock Holmes books and I'm attempting to read the Autobiography of Benjamin Franklin and Physics for Entertainment now.

I put it in a clipboard I bought at Office Depot -- one of those storage clipboard cases -- for protection from damage/theft.  I am working on making a USB drive with the PortableApps to create my perfect portable experience now, to use while rounding in the hospital.

I do enjoy the multiple formats that I can use to read my Kindle books -- it is nice to curl up in bed with my Kindle app on the iPhone when I don't want to read with the lights on.

 

The only thing I dislike about the Kindle is the bookmarking -- there's no way to label the bookmarks so it is a lot of page number memorization!  Very frustrating when you're trying to navigate to something specific as a quick reference.

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Picture by ivyfield via flickr