Monday, 12 September 2016

Physical examination is reclaimed

Acute vestibular syndrome, characterized by dizziness, nausea and vomiting, is often due to a local neuritis of the inner ear, despite the fact that a doctor cannot overlook that with these symptoms he or she must first rule out the vertebrobasilar stroke, a less common aetiology, but obviously a lot more serious. I chose this health condition because the neurologist David Newman-Toker from Johns Hopkins (and the team) have systematized HINTS (Head Impuls, Nystagmus and a Test Skew), an examination that requires nothing more than some basic neurologist’ tasks: a) the patient is asked to move his head while focusing at the examiner’s nose; b) the nystagmus is measured on lateral gaze, and c) one of the patient's eyes is covered with the hand while the other eye will focus at the examiner’s  nose and then the other eye is suddenly uncovered. On the understanding that family physicians and emergency room doctors know how to do this (and they probably do) the essential neurological examination before a persistent vestibular syndrome, should be aware that the study published by the team Newman-Toker in the Stroke journal states that HINTS has shown 100% sensitivity and 96% specificity so that the doctor can rule out the vertebrobasilar stroke in people with acute vestibular syndrome, values exceeding those of nuclear magnetic resonance.

Emergency room visits for ankle sprains are very common and pose the clinical problem of having to rule out a bone fracture, which occurs in 15% of cases. Although the usual way of handling the situation is usually the radiological assessment by an orthopaedic surgeon, a Canadian group wanted to reclaim the physical examination over the radiology and assessed the impact of ankle exploration, which is now known as "Ottawa ankle rules": a) to insist on the need for an ankle x-ray there must be ankle pain, or b) sensitivity to pain on palpation of the extremity and at the back of the lateral malleolus, or c) the same criteria for the internal malleolus, or d) inability to climb four stairs while carrying weight. As seen in the chart, there is a variation of "Ottawa ankle rules" to rule out broken bones of the foot where the examination of the malleolus is replaced by that of the base of the fifth metatarsal and the navicular area. What the Canadians tell us is that before ordering an ankle x-ray, we must note that in a systematic review of 32 studies involving more than 15,000 patients, "Ottawa ankle rules" has shown a sensitivity of 100% for detecting fractures.

HINTS and "Ottawa ankle rules" are based on well known physical examinations. The novelty is that now they claim, with results, that in certain fields, clinical examination capacity can compete with prestigious imaging tests, which, apart from the economic issues, also has the advantage of preventing any delays, unnecessary radiation and sometimes cumbersome radiological contrast.

Jordi Varela

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