Tuesday, November 9, 2010

Physical Exam Tapas



Today we saw some great cases:


  • Erythema Nodosum: discussed here. Secondary to sarcoid? TB?

  • CREST syndrome: discussed here.

  • Pulmonary Hypertension: discussed here. Secondary to Ebstein's anomaly.

Tuesday, November 2, 2010

Parkinson's Disease


Today we saw a gentleman with Parkinson's Disease. A few features to watch for on the physical exam.
  • Head and Neck: Look for a masked facies, seborrhea, absence of blinking, and possibly drooling. In addition, the glabellar tap maneuver is often positive, but not a very nice exam to perform.
  • Listen: Speech is often soft, slow, and monotonous.
  • Tremor: This is at rest, and initially starts unilaterally. Often described as a 'pill rolling' tremor with 4-6 cycles per second. It will eventually move bilaterally.
  • Tone: Classically with 'cogwheel' vs lead pipe rigidity. We felt a good example of cogwheeling today.
  • Bradykinesia: Slower movements. You can bring this out by having them pretend to play the piano, heel tapping, etc.
  • Gait: Watch for a stooped posture ('simian posture'), with a shuffling ('festinating') gait. It appears as if their center of gravity is just in front of them. Watch closely when turning around - this often requires multiple little steps rather than just one or two steps.
  • Other: Watch for micrographia (small writing), difficulty opening jars, difficulty turning in bed, difficulty going from a sit-to-stand.
Here is an excellent JAMA article on the clinical evaluation of Parkinson's Disease.