In Episode 5, I present Beachside Rounds, a fun activity for the whole family this summer, and a brief introduction into interesting physical exam findings.
The Tetris effect, according to my expert consultant Dr. Wikipedia, occurs when people devote so much time and attention to an activity that it begins to pattern their thoughts, mental images, and dreams.. Practicing medicine is basically practicing the tetris effect. Every day the physician looks for patterns, in patient’s histories, physicals, lab values, and imaging studies to help define and untangle illnesses. You can imagine that this pattern recognition is difficult to turn off, even when you’re on vacation. A brief aside on the actual effects of tetris on cognition, there have been actual clinical studies on the matter, including, shockingly, using tetris as a “cognitive vaccine” for flashbacks in patients with PTSD.
So six months ago, I was relaxing at a beach in Hawaii — I know, my life is very difficult — and I couldn’t help myself; physical exam findings on my fellow beach-goers kept popping out to me, like tetronimos on a tile ceiling. And actually, if you think about it, in many ways, the beach is an ideal venue to practice physical exam skills, mostly because patients (er, beach goers) are mostly disrobed, and there’s a surprisingly amount of pathology present. So with that, I give you “Beachside Rounds,” a rough guide to a physical exam you can do, well, next summer, since labor day just passed. There is, of course, a caveat, but dont’ worry, I’ll spoil the fun at the end.It involves biostatistics. Consider yourself forewarned.
The physical exam traditionally have three parts — inspection, auscultation, and palpation. I don’t expect you to put your ear against people’s chests (and please don’t carry a travel stethoscope), and we’ll certainly not be touching anyone, so let’s just stick with inspection, also known as “looking”. Sun glasses can be helpful if you’re a gawker. Doctors have been naming physical exam findings (often after themselves) for nigh on 500 years, so I’ll limit myself to one per system. We usually divide our physical exam into systems, from head to toe, so that’s what I’ll be doing here.
So the first category is general, which is a bit of a cop-out because it really isn’t a body system. Lots of great stuff to spy on your neighbors with, but we’ll start with a condition called “cachexia”, which aptly means “bad condition” in Greek, and basically refers to wasting seen in chronic illness.
Then comes the HEENT exam, an acronym that stands for head, ears, eyes, nose, and throat. If the man sunbathing to you has an especially protuberant forehead, he might have “frontal bossing”, an enlargement of the frontal bone of the skull. Think Andre the Giant, and like him, it’s a fairly specific finding for acromegaly, or gigantism, in adults. For ears, we have my favorite physical exam finding, Frank’s sign, or the diagonal earlobe crease, which is the entire subject of my first episode. Spoiler alert — it’s a reasonably specific sign for heart disease. Eyes are the window to the soul, but they’re also the window to your body’s bilirubin level, a breakdown product for red blood cells and an important marker in bilirubin disease. If your neighbor has a faint yellowish tinge to their eye, we call this scleral icterus, and you can even guess that their bilirubin level is about 2.5 mg/dl. You might happen across someone with a saddle nose deformity, which happens when the bridge of the nose collapses. These days it’s due mostly to trauma, but before the days of antibiotics a common cause was congenital syphilis. Cocaine does it too, as do autoimmune disease like Wegener’s and sarcoid. And for throat — well, if you’re getting a good view of someone’s throat at the beach, you relax a little differently than I do.
For the neck, we have the unfortunately named Buffalo hump, a fat pad on the back of the neck that is caused by exposure to cortisol. These days it’s usually caused by people on steroids for chronic medical conditions, but can classically be caused by enlargement of the adrenal gland or from the pituitary gland in the brain.
The next system is the respiratory system, and you might think that it would be difficult to examine the lungs at the beach. But a nice short hand — a pun, if you will — is to check out the fingernails. If the nails are thickened, widened, and flattened, we call this clubbing, and is a sign of underlying lung or heart disease.
Next we come to the cardiovascular system, and like the lungs, it should be difficult to do one of these from afar. But I like to look out for the sternotomy scar, a vertical line down the patient’s chest that shows where his or her chest was cracked for a cardiac bypass, and probably a sensitive marker for cardiac disease, major caveat being that I’ve done 0 research on this topic. (sure, there are other reasons to get a sternotomy, but a byoass is one of the most likely). As a corollary, I also like to check out for scars on the legs to see how much of the saphenous vein was taken for the bypass. Again, I have done absolutely 0 research on this, and I couldn’t find any of PubMed, but I’d i imagine the larger the saphenous scar, the worse the disease in the heart.
The abdominal exam is next, and here we have something called “caput medusae”, or Medusa’s Head, which refers to engorged umbilical veins in the abdomen, splayed out from the umbilicus much like the snakes on Medusa’s head. It’s a sign of increased pressures in the liver vasculature, and often seen in cirrhosis.
Traditionally, the pelvic and genitourinary exams come next, but that’s considered in poor form at most beaches, so moving on. And for the lymphatic system, I don’t have any good beach hacks either, so moving on there too.
And we’re on to one of my favorites, the neurological exam. You can tell a ton about neurological conditions just by looking at them … much more than I can mention here (and since I’ve purposely limited myself to one finding per system). For example, you can localize strokes with surprising accuracy just with careful observation (and a few tests). But my beachside pearl is to look at how people walk. Gait can tell us a ton about what’s going on in the nervous system, and there are tons of interesting videos online. I feel bad just picking one, but we’ll talk about the marche a petis pas, which is the gait we see in Parkinson’s disease. It means “walk of little steps”, and that’s pretty much what it is — Parkinson’s makes people rigid and makes it difficult to initiate steps, so you will see the patient take very slow, small, and deliberate steps. All of these gaits are difficult to describe, so I’d recommend looking them up on Youtube.
And the final system is the psychiatric exam. How can simple observation tell you something about a fellow beachgoer’s psychiatric status? Well, it can’t, not really, but I like to look out for tardive dyskinesia, involuntary and repetitive motions, such as grimacing, that are unfortunate side effects of long-term use of antipsychotic medications, especially older ones.
So that’s it for the exam. Now here comes the caveat part. How useful are these exam findings? This is going to take a very quick refresher on likelihood ratios. So a likelihood ratio is the ratio of people with a physical exam finding with the disease to the ratio of people without the disease with the finding. The higher the number, the more likely the person has the disease; the closer to 0, the less likely the person has the disease, and a LR of 1 doesn’t give you any extra information. How much more of less likely you are depends on the prevalence, or percentage of the population that has the disease. And this shows you where we can get into trouble with beachside rounds.
Caput medusae probably has the highest likelihood ratio among the group we studied here —
for cirrhosis, it’s 10. I have no idea what the prevalence of cirrhosis in the beach-going population is, but I assume it’s close to the US average, which is 0.15%. So consulting my handy likelihood ratio nomogram, this would increase the chance that the person has cirrhosis from 0.15% to a whopping 5%. Something like clubbing, which has an LR of 4 for lung cancer, looks even worse. The prevalence of lung cancer in the general population is similar actually to cirrhosis, about 0.13%. So if your neighbor has clubbed fingernails, the chance they have lung cancer has increased from about 0.13% to something like 3%.
So what’s the point of even looking? The answer, of course, is that my exam room, or the hospital, is not the beach. We have a little bit more information. Maybe that gentleman with caput medusae has hepatitis C, and has been complaining of abdominal swelling. Well, his pre-test probability of cirrhosis is probably more like 50%, which with an LR of 10 would make the chance of him having cirrhosis close to 90%. And let’s say your patient with clubbing has a 50 pack-year history of smoking. Maybe the pre-test probability of cancer is 20%. That puts the chance of cancer to over 50%, and you can bet that I’ll get a chest x-ray.
So Beachside Rounds, you see, is a fun academic exercise, and a good way to wile away some time at the beach when you’re not, uh, surfing some tubes. Yeah, I don’t know surfing lingo. But it’s probably not the best for actually diagnosing patients at the beach. Is it that useful for diagnosing patient’s in the office or hospital? Well, that’s a question for another podcast, where I will probably talk about likelihood ratios even more. In the meantime, that’s it for our show. Do you have a favorite physical exam finding that I left out? Well, you’re in luck. Visit our website at www.bedside-rounds.org, or find me on Twitter @AdamRodmanMD, and let me know. And as always, thanks for listening.
Want to read more about the physical exam? Oh boy do I have a treat for you. I use Evidence Based Physical Diagnosis, by Dr. Steve McGee, which is my source for most of my likelihood ratios. I’d also use google image search and youtube to look at any of the findings discussed here, and I will link on the website.