SERENITY NOW Posted February 13, 2019 Author Share Posted February 13, 2019 Wanted to resurrect this old thread to share another VERY useful exam finding that has changed my practice... I now look for this every shift in the ED: Spontaneous Venous Pulsations ("SVP", as part of the fundoscopic exam). I use it as part of my assessment for every patient presenting with headache, neurological complaints, severely elevated blood pressure, etc. I started doing this a couple of years ago after hearing Greg Henry, a legendary EM lecturer and expert on everything medicolegal and neurology. One of his main take home points was that you haven't completed a thorough neuro exam until you've looked in their eyes and watched them walk. People will say the fundoscopic exam is too hard to do on a nondilated pupil, but let me tell you that after practicing this for 1 week, you'll have it down, and after a few months you'll be able to get it done in about 30 seconds. How does the exam technique work? Dim the lights, have the patient focus on a specific point across the room (use accommodation to dilate the pupils as much as you can), start by looking nasally, find any eye vessel and follow it both ways until you find the optic disc, and look for the pulsing vein. Done; its really quick and simple. Its easier to find this than papilledema in my opinion, and its present in the vast majority of patients... Why is it important? The presence of SVP essentially rules out elevated intracranial pressure, which can be seen in a TON of conditions. Conditions like space occupying lesions (tumor, abscess, bleed with mass effect), increase intracranial fluid production (pseudo tumor cerebri, meningitis), outflow decreases (hydrocephalus, cerebral venous thrombosis).... So, by confirming normal ICP, the likelihood of all of these things decreases substantially. The majority of headache patients need no emergent workup in the ER, but you need to do a thorough clinical evaluation. If there are no red flags on Hx, exam is normal including neuro exam, patient has a normal gait, and spontaneous venous pulsations are present, the likelihood of an emergency is quite low and I can focus on just treating symptoms. This saves a lot of unnecessary spending and wasted ED bed space! Give it a try! https://jnnp.bmj.com/content/74/1/7 Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 13, 2019 Share Posted February 13, 2019 This is one of GMOTM's favorite look/see's. For pharyngitis cases, pay attention to the appearance of the injection as well as the presence/absence of small papules on the oropharynx. If a linear strip is noted retro-uvula, or the patient has a "splattered red paint" appearance across the pharynx, then this is most likely due to post-nasal drip. A "well painted wall", otherwise known as confluent erythema, to the pharynx is more commonly associated with primary pharyngitis. One will typically find that the former is variable in severity with most severe sx. nocturnally and upon awakening (acidity of PND) whereas the primary pharyngitis/tonsillitis is relatively constant in severity regardless of time. The former patients are the ones who do will with hs swallows of liquid antacid. Link to comment Share on other sites More sharing options...
AshySlashy Posted February 13, 2019 Share Posted February 13, 2019 On 8/13/2015 at 8:55 AM, SERENITY NOW said: An anesthesiologist showed me Pemberton's sign in a patient with lung cancer, indicating it was also causing superior vena cava syndrome. Pemberton's sign: The maneuver is achieved by having the patient elevate both arms until they touch the sides of the face. A positive Pemberton's sign is marked by the presence of facial congestion and cyanosis, as well as respiratory distress after approximately one minute. We learned about Pemberton's sign in the context of thyroid goiter. I'd like to add: Trousseau sign: "Test for the Trousseau sign by placing a blood pressure cuff on the patient’s arm and inflating to 20 mm Hg above systolic blood pressure for 3-5 minutes. This increases the irritability of the nerves, and a flexion of the wrist and metacarpal phalangeal joints can be observed with extension of the interphalangeal joints and adduction of the thumb (carpal spasm). The Trousseau sign is more specific than the Chvostek sign but has incomplete sensitivity." Also, I thought the back story for de Musset's sign was interesting. Link to comment Share on other sites More sharing options...
Colorado Posted February 21, 2019 Share Posted February 21, 2019 RAPD. Walk in to my FP clinic a few months ago. Quite a good finding to show our student that day. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 21, 2019 Share Posted February 21, 2019 Had a patient yesterday presenting with "sore under the tongue". Look under the tongue and looking back at me was a stone in the lingual frenulum. Second time I've seen one in 36 years. Pressed on the left SMG and low and behold it was tender. First one I ever saw I missed, but it was picked up by the ED director (of course he did). Used a split lengthwise tongue blade to milk it out and then with pressure to the SMG it was like a spitting cobra with foul discharge coming out of the duct opening. Brought the staff in yesterday to see it since odds are they won't ever see another one. I wasn't able to milk it out in the same manner due to tenderness so I went with the straight on treatment of amoxicillin, if stone not passed in 48 hours see ENT, and of course the most painful therapy of all...go get some Lemonheads, Sweetarts, or some such and milk that gland/duct for all it's worth. Link to comment Share on other sites More sharing options...
Guest JMPA Posted February 21, 2019 Share Posted February 21, 2019 Darier sign, i just like to draw on my patients Link to comment Share on other sites More sharing options...
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