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Altering baseball pitching mechanics affects both performance and the risk of injury. The purpose of this study is to investigate the relationships of shoulder external over internal rotation ratio (SEIR) and other shoulder rotational properties during physical exam and biomechanics of pitching for 177 collegiate baseball pitchers. The shoulder range of motion was quantitatively measured using a custom-made wireless device. Pitching motion data were collected at 240 Hz, and a custom program was created to calculate the throwing arm motion and loading during baseball pitching. Linear regression and analysis of variance tests were performed to investigate the relationships between the shoulder physical exam outcomes and throwing arm biomechanics. SEIR had significant correlations with shoulder horizontal adduction angle at foot contact, maximum shoulder external rotation angle, maximum shoulder linear velocity, and elbow angle at ball release. SEIR groups had significant differences in shoulder proximal force, adduction torque, internal rotation torque, and horizontal adduction torque, and in elbow medial force and varus torque. Glenohumeral internal rotation deficit and total rotational motion deficit had no relationships with throwing arm motions or joint loadings. Shoulder health should be monitored to improve understanding of pitching mechanics in collegiate baseball pitchers. [ABSTRACT FROM AUTHOR]

Few studies have assessed the ability of internal medicine residents to perform a cardiovascular physical examination using real patients. First year internal medicine interns from 2 large academic medical centers in Maryland examined the same patient with aortic insufficiency as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were assessed on 5 clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs. One hundred nine interns examined the same patient with aortic insufficiency across 14 APECS sessions. Only 58 interns (53.2%) correctly identified the presence of a diastolic murmur, and only 52 interns (47.7%) included aortic insufficiency on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of the correct physical findings (r = 0.42, P <.001). Both technique (r = 0.34, P =.003) and identifying findings (r = 0.42, P <.001) were significantly associated with generating an appropriate differential diagnosis. Common errors in technique included auscultating over the gown, timing the cardiac cycle with the radial pulse, and failing to palpate for the apical impulse. Internal medicine interns had variable skills in performing and interpreting the cardiovascular physical exam. Improving cardiovascular exam skills would likely lead to increased identification of relevant cardiovascular findings, inform clinical decision making and improve overall patient care. [ABSTRACT FROM AUTHOR]

Purpose: Radial tunnel syndrome (RTS) is a controversial diagnosis due to non-specific exam findings and frequent absence of positive electromyography (EMG) and nerve conduction study (NCS) findings. The purpose of this study was to identify the methods used to diagnose RTS in the literature. Methods: We queried PubMed, Embase, Web of Science, and Cochrane databases per PRISMA guidelines. Extracted data included article and patient characteristics, diagnostic assessments utilized and their respective findings, and treatments. Objective data were summarized descriptively. The relationship between reported diagnostic findings (i.e., physical exam and diagnostic tests) and treatments was assessed via a descriptive synthesis. Results: Our review included 13 studies and 391 upper extremities. All studies utilized physical exam in diagnosing RTS; most commonly, patients had tenderness over the radial tunnel (381/391, 97%). Preoperative EMG/NCS was reported by 11/13 studies, with abnormal findings in 8.9% (29/327) of upper extremities. Steroid and/or lidocaine injection for presumed lateral epicondylitis was reported by 9/13 studies (46/295 upper extremities, 16%), with RTS being diagnosed after patients received little to no relief. It was also common to inject the radial tunnel to make the diagnosis (218/295, 74%). The most common reported intraoperative finding was narrowing of the PIN (38/137, 28%). The intraoperative compressive site most commonly reported was the arcade of Frohse (142/306, 46%). Conclusions: There is substantial heterogeneity in modalities used to diagnose RTS and the reported definition of RTS. This, in conjunction with many patients having concomitant lateral epicondylitis, makes it difficult to compare treatment outcomes for RTS. Level of evidence: Level III. Systematic review of retrospective and prospective cohort studies [ABSTRACT FROM AUTHOR]

In the U.S., diagnostic errors are common across various healthcare settings due to factors like complex procedures and multiple healthcare providers, often exacerbated by inadequate initial evaluations. This study explores the role of Large Language Models (LLMs), specifically OpenAI's ChatGPT-4 and Google Gemini, in improving emergency decision-making in plastic and reconstructive surgery by evaluating their effectiveness both with and without physical examination data. Thirty medical vignettes covering emergency conditions such as fractures and nerve injuries were used to assess the diagnostic and management responses of the models. These responses were evaluated by medical professionals against established clinical guidelines, using statistical analyses including the Wilcoxon rank-sum test. Results showed that ChatGPT-4 consistently outperformed Gemini in both diagnosis and management, irrespective of the presence of physical examination data, though no significant differences were noted within each model's performance across different data scenarios. Conclusively, while ChatGPT-4 demonstrates superior accuracy and management capabilities, the addition of physical examination data, though enhancing response detail, did not significantly surpass traditional medical resources. This underscores the utility of AI in supporting clinical decision-making, particularly in scenarios with limited data, suggesting its role as a complement to, rather than a replacement for, comprehensive clinical evaluation and expertise. [ABSTRACT FROM AUTHOR]

With the rapid adoption of telemedicine since the COVID-19 pandemic, it has become imperative to teach and evaluate health professional trainees on skills important to conducting effective virtual visits. We developed a simulation-based workshop with (1) readings, (2) a lecture covering online communication and the virtual head and neck exam, (3) a telemedicine simulation with a standardized patient observed by faculty, (4) personalized feedback from faculty, and (5) a group debrief session. We created an evaluation rubric based on three of 20 Association of American Medical Colleges (AAMC) telemedicine competencies to assess learner performance during the simulations. Students (medical and physician assistant students; n = 50), and internal medicine residents (n = 20) completed this workshop in 2023. At least 90% of trainees across the two groups were rated as approaching entrustment or entrustable in each competency. This workshop is an example of a scalable telemedicine curriculum that can be used to teach and evaluate learners in the virtual physical exam across the training continuum. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Musculoskeletal injuries are one of the more common injuries in spaceflight. Physical assessment of an injury is essential for diagnosis and treatment. Unfortunately, when musculoskeletal injuries occur in space, the flight surgeon is limited to two-dimensional videoconferencing and, potentially, observations made by the crew medical officer. To address these limitations, we investigated the feasibility of performing physical examinations on a three-dimensional augmented reality projection using a mixed-reality headset, specifically evaluating a standard shoulder examination. METHODS: A simulated patient interaction was set up between Western University in London, Ontario, Canada, and Huntsville, AL, United States. The exam was performed by a medical student, and a healthy adult man volunteered to enable the physical exam. RESULTS: All parts of the standard shoulder physical examination according to the Bates Guide to the Physical Exam were performed with holoportation. Adaptation was required for the palpation and some special tests. DISCUSSION: All parts of the physical exam were able to be completed. The true to anatomical size of the holograms permitted improved inspection of the anatomy compared to traditional videoconferencing. Palpation was completed by instructing the patient to palpate themselves and comment on relevant findings asked by the examiner. Range of motion and special tests for specific pathologies were also able to be completed with some modifications due to the examiner not being present to provide resistance. Future work should aim to improve the graphics, physician communication, and haptic feedback during holoportation. [ABSTRACT FROM AUTHOR]

Objective: The clinical evaluation of palpable neck masses usually underestimates or overestimates their extension. A neck mass is defined as any increase in volume that forms in the cervical region, of congenital or acquired origin and that is visible, palpable, or identified by means of an imaging study. Method: An extensive bibliographic review was carried out in the PubMed database, where recent bibliographic information was inquired using the following keywords: cervical mass in adults, neck mass in adults, cervical lymphadenopathy in adults, as well as on evaluation methods such as ultrasound (US) and computed tomography, including original studies, and bibliographic reviews. Results: The manuscript indicates the CRISPS mnemonic, the CLN-RADS (Cervical Lymph Node Imaging Reporting and Data System for ultrasound of Cervical Lymphadenopathy) as well as the proposal of the UNN-RADS (Ultrasound Neck Node Reporting and Data System) classification, and how US examination of the neck should be performed with a systematic approach, organized to evaluate, and report cervical lymph nodes and do not omit any ganglionic chain. In current medical practice, there is often no defined clinical picture when a neck mass appears in adults and reflects a severe abnormality. Conclusion: A new persistent neck mass in an adult patient should be considered malignant until proven otherwise. Any neck mass, particularly unilateral, asymptomatic, in cervical lymph node group topography, should be considered a metastatic lesion, until proven otherwise. [ABSTRACT FROM AUTHOR]

Abstract Background Faculty have traditionally taught the physical examination (PE) to novice medical students (pre-clerkship students.), despite recruiting and cost issues and problems standardizing their approach. Activity We present a model using standardized patient instructor (SPI)-fourth year medical student (MS4) teams to teach PE to pre-clerkship students, leveraging the benefits of co-teaching and peer-assisted learning. Results Surveys of pre-clerkship students, MS4s and SPIs indicate positive perceptions of the program, including MS4s reporting significant growth in their professional identities as educators. Pre-clerkship students' performance on the spring clinical skills exams was equivalent to or better than their peer performance pre-program implementation. Implications SPI-MS4 teams can effectively teach novice students the mechanics and clinical context of the beginners’ physical exam.

Background: Faculty have traditionally taught the physical examination (PE) to novice medical students (pre-clerkship students.), despite recruiting and cost issues and problems standardizing their approach. Activity: We present a model using standardized patient instructor (SPI)-fourth year medical student (MS4) teams to teach PE to pre-clerkship students, leveraging the benefits of co-teaching and peer-assisted learning. Results: Surveys of pre-clerkship students, MS4s and SPIs indicate positive perceptions of the program, including MS4s reporting significant growth in their professional identities as educators. Pre-clerkship students' performance on the spring clinical skills exams was equivalent to or better than their peer performance pre-program implementation. Implications: SPI-MS4 teams can effectively teach novice students the mechanics and clinical context of the beginners' physical exam. [ABSTRACT FROM AUTHOR]

Objective: To compare the effect of virtual and in-person head and neck physical examination training events on medical student confidence in performing examination maneuvers and seeking mentorship from otolaryngology faculty and residents. Methods: Training events were held with first-year medical student volunteers in 2020 (in-person) and 2021 (virtual). Participants in both cohorts were given didactics on head and neck cancer, trained to perform a head and neck physical examination, and demonstrated their clinical skills to otolaryngology faculty and residents. Pre- and post-training surveys were utilized to assess the following outcomes: participant head and neck cancer knowledge, confidence in performing examination maneuvers, and confidence in seeking mentorship in otolaryngology. Differences in outcomes between training settings were assessed by comparing participant survey responses pre- and post- training. Results: Both in-person and virtual training modalities improved participant confidence in performing the physical examination. There was no significant difference in the degree of improvement between training types. In-person training significantly increased participant confidence in seeking mentorship from otolaryngology faculty and residents (P =.003), while virtual training did not (P =.194). Conclusion: Virtual training modalities are feasible methods of teaching the head and neck physical examination. Instruction through a video conferencing platform has the potential to be incorporated into traditional in-person medical education in a permanent fashion. This pilot study can inform future studies directly comparing in-person and virtual physical examination training modalities. [ABSTRACT FROM AUTHOR]

BackgroundSmartphone technology is ubiquitous throughout neurologic practices, and numerous apps relevant to a neurologist's clinical practice are now available. Data from other medical specialties suggest high utilization of smartphones in routine clinical care. However, the ways in which these devices are used by neurologists for patient care-related activities are not well defined.ObjectiveThis paper aims to characterize current patterns of smartphone use and perceptions of the utility of smartphones for patient care-related activities among academic neurology trainees and attending physicians. We also seek to characterize areas of need for future app development.MethodsWe developed a 31-item electronic questionnaire to address these questions and invited neurology trainees and attendings of all residency programs based in the United States to participate. We summarized descriptive statistics for respondents and specifically compared responses between trainees and attending physicians.ResultsWe received 213 responses, including 112 trainee and 87 attending neurologist responses. Neurology trainees reported more frequent use of their smartphone for patient care-related activities than attending neurologists (several times per day: 84/112, 75.0% of trainees; 52/87, 59.8% of attendings; P=.03). The most frequently reported activities were internet use, calendar use, communication with other physicians, personal education, and health care-specific app use. Both groups also reported regular smartphone use for the physical examination, with trainees again reporting more frequent usage compared with attendings (more than once per week: 35/96, 36.5% of trainees; 8/58, 13.8% of attendings; P=.03). Respondents used their devices most commonly for the vision, cranial nerve, and language portions of the neurologic examination. The majority of respondents in both groups reported their smartphones as "very useful" or "essential" for the completion of patient care-related activities (81/108, 75.0% of trainees; 50/83, 60.2% of attendings; P=.12). Neurology trainees reported a greater likelihood of using their smartphones in the future than attending neurologists ("very likely": 73/102, 71.6% of trainees; 40/82, 48.8% of attendings; P=.005). The groups differed in their frequencies of device usage for specific patient care-related activities, with trainees reporting higher usage for most activities. Despite high levels of use, only 12 of 184 (6.5%) respondents reported ever having had any training on how to use their device for clinical care. Regarding future app development, respondents rated vision, language, mental status, and cranial nerve testing as potentially being the most useful to aid in the performance of the neurologic examination.ConclusionsSmartphones are used frequently and are subjectively perceived to be highly useful by academic neurologists. Trainees tended to use their devices more frequently than attendings. Our results suggest specific avenues for future technological development to improve smartphone use for patient care-related activities. They also suggest an unmet need for education on effectively using smartphone technology for clinical care.

Lipodystrophy syndromes are rare metabolic disorders characterized by local or generalized loss of adipose tissue, resulting in insulin resistance, dyslipidemia, and cosmetic disfiguration. The lipodystrophic phenotype is highly variable, with partial lipodystrophy often missed or misdiagnosed as other diseases from a lack of a proper physical examination and low physician awareness. Correct diagnosis is important for optimal treatment and follow-up strategies in these patients. The use of GLP-1 analogs has not been systematically evaluated in lipodystrophy and could be a potential precision medicine therapy. We aim to make the reader, particularly generalists or endocrinologists outside of tertiary referral centers, aware of the presentation and clinical features of partial lipodystrophy, emphasize the role of a full physical examination in diagnosis, and discuss therapeutic options, including GLP-1–based glycemic management illustrated by our clinical case. [ABSTRACT FROM AUTHOR]

The aim of the study was to analyze the teaching-learning process in the discipline of nursing semiology and semiotics. Cross-sectional study, with the participation of 110 nursing students from a public university in the center-south of Ceará, Brazil. Data were obtained through an electronic questionnaire, organized in Google Forms®, grouped in a Microsoft Excel® spreadsheet and analyzed for descriptive and inferential statistics. Students who debated or were proactive had higher averages in the discipline than those who never did. These recognized the relevance of the discipline in intellectual training and its essentiality for professional practice, however, they attribute a medium to high degree of difficulty to the discipline. The teaching-learning process in the discipline of nursing semiology and semiotics requires a multiple combination of pedagogical methods that promote the development of competences for the future performance of nurses, contemplating meaningful learning and the use of active methodologies. [ABSTRACT FROM AUTHOR]

(1) Background: The objective was to compare the exploration of chronic pelvic pain syndrome (CPPS) patients in different locations and establish the role of physical examination in CPPS patients. (2) Methods: We reviewed clinical data from 107 female patients with CPPS unresponsive to conventional therapies at Puerta de Hierro University Hospital Madrid, Spain, from May 2018 to June 2022. Patients were classified into three groups: (a) pelvic pain; (b) anorectal pain; or (c) vulvar/perineal pain. (3) Results: Although the demographics of patients with CPPS were different, their physical examinations were strikingly similar. Our study observed a comorbidity rate of 36% and 79% of central sensitization of pain. Seventy-one percent of patients had vulvar allodynia/hyperalgesia. Pain on examination was identified in any pelvic floor muscle, in any pelvic girdle structure, and neuropathic pain in 98%, 96%, and 89%, respectively. Patients with vulvar and perineal pain were more different from the other groups; these patients were younger and had fewer comorbidities and less central sensitization, less anorectal pain, more pain during intercourse, and greater nulliparity (p = 0.022; p = 0.040; p = 0.048; p = 0.000; p = 0.006; p = 0.005). (4) Conclusions: The findings of this study are related to the understanding of the pathophysiology of CPPS. The physical examination confirms the central sensitization of female patients with CPPS, helps us to determine the therapeutic management of the patient, and can be considered as a prognostic factor of the disease. [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic ushered in a rapid, transformative adoption of telemedicine to maintain patient access to care. As clinicians made the shift from in-person to virtual practice, they faced a paucity of established and reliable clinical examination standards for virtual care settings. In this systematic review, we summarize the accuracy and reliability of virtual assessments compared with traditional in-person examination tools. Methods: We searched PubMed, Embase, Web of Science, and CINAHL from inception through September 2019 and included additional studies from handsearching of reference lists. We included studies that compared synchronous video (except allowing for audio-only modality for cardiopulmonary exams) with in-person clinical assessments of patients in various settings. We excluded behavioral health and dermatological assessments. Two investigators abstracted data using a predefined protocol. Results: A total of 64 studies were included and categorized into 5 clinical domains: neurological (N = 41), HEENT (head, eyes, ears, nose, and throat; N = 5), cardiopulmonary (N = 5), musculoskeletal (N = 8), and assessment of critically ill patients (N = 5). The cognitive assessment within the neurological exam was by far the most studied (N = 19) with the Mini-Mental Status Exam found to be highly reliable in multiple settings. Most studies showed relatively good reliability of the virtual assessment, although sample sizes were often small (<50 participants). Conclusions: Overall, virtual assessments performed similarly to in-person exam components for diagnostic accuracy but had a wide range of interrater reliability. The high heterogeneity in population, setting, and outcomes reported across studies render it difficult to draw broad conclusions on the most effective exam components to adopt into clinical practice. Further work is needed to identify virtual exam components that improve diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Point-of-care ultrasound aims to enhance physical examination findings with real-time information from the ultrasound. Peritoneal dialysis catheter-related infections are a frequent complication of peritoneal dialysis and a major predisposing factor to peritonitis. The diagnosis of peritoneal dialysis catheter-related infections is made with physical examination, but physical findings usually lack sensitivity or specificity. This is a single-center observational study that aimed to evaluate the accuracy of point-of-care ultrasound for the diagnosis of peritoneal dialysis catheter-related infections. Sixteen peritoneal dialysis patients with peritoneal dialysis catheter-related infections clinical suspicion were enrolled in this study, as well as nine controls. Peritoneal dialysis catheter-related infection was defined as a purulent discharge with or without inflammatory signs in the peritoneal dialysis catheter exit-site or subcutaneous tunnel, and a positive microbiological culture collected from the exit-site. Point-of-care ultrasound was considered positive when an anechoic collection in relation to the external cuff or catheter tunnel was identified. Physical examination findings were coded using the Exit-site Scoring System. A total of 13 peritoneal dialysis catheter-related infections were diagnosed. The mean Exit-site Scoring System score for the suspected cases of peritoneal dialysis catheter-related infections was 2,82 ± 1,22, and the most commonly encountered sign was purulent discharge. All of the cases of peritoneal dialysis catheter-related infections had a positive point-of-care ultrasound. In contrast, none of the controls had a positive point-of-care ultrasound (p < 0,001). The area under the receiver operating characteristic curve of physical examination for the diagnosis of peritoneal dialysis catheter-related infections was 0,6 (95% CI 0,37-0,84). In contrast, point-of-care ultrasound had an AUROC of 0,91 (95% CI: 0,73-1) for the diagnosis of peritoneal dialysis catheter-related infections. Nephrologist-performed point-of-care ultrasound is feasible and superior to physical examination for the diagnosis of peritoneal dialysis catheter-related infections.

Lack of standardized definition impedes our ability to understand the clinical significance of asymptomatic central venous catheter (CVC) associated deep venous thrombosis (CADVT). Using standardized definitions, we aimed to determine the accuracy of physical examination in detecting CADVT in critically ill children and to identify characteristics associated with this accuracy. In a post hoc study, we analyzed 236 children <18 years old admitted to the pediatric intensive care unit, had an untunneled CVC and surveilled for CADVT using ultrasound with paired physical examination. Of 236 paired examinations, 79 (33.5 %) had CADVT on ultrasound, while 56 (23.7 %) had signs of inflammation or venous obstruction on physical examination or CVC dysfunction. Sensitivity was 29.2 % (95 % confidence interval, CI: 19.9 %, 38.5 %), specificity was 80.2 % (95 % CI: 73.9 %, 86.4 %) and area under the receiver operating characteristic curve (AUROC) was 0.55 (95 % CI: 0.49, 0.60). When CVC dysfunction was excluded, sensitivity was lower (11.1 %; 95 % CI: 4.6 %, 17.6 %; p = 0.002), but specificity was higher (88.7 %; 95 % CI: 83.6 %, 93.7 %, p = 0.04). AUROC was 0.50 (95 % CI: 0.46, 0.54; p = 0.17). Use of point-of-care ultrasound and CVC inserted in the internal jugular vein (vs femoral vein) had lower sensitivity. Sepsis or infection and vasoactive support had lower specificity. Center of enrollment was associated with variable sensitivity. Physical examination has poor accuracy in detecting CADVT in critically ill children. Despite poor accuracy, physical examination that includes assessment of CVC dysfunction, in combination with imaging, is key to understanding the clinical significance of asymptomatic CADVT. [ABSTRACT FROM AUTHOR]

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Keywords: assessment; feedback; physical exam EN assessment feedback physical exam 393 397 5 09/01/22 20220801 NES 220801 To the Editor, Recent data highlights that the bedside clinical skills of twenty-first century physicians are declining. A consequence of physical exam skills not being taught or assessed in residency is that many faculty do not feel comfortable with their own ability to teach physical exam technique [[4]]. [Extracted from the article]

Background: Assessment of mortise stability is paramount in determining appropriate management of ankle fractures. Although instability is readily apparent in bimalleolar or trimalleolar ankle fractures, determination of instability in the isolated Weber B fibula fracture often requires further investigation. Prior authors have demonstrated poor predictive value of physical examination findings such as tenderness, ecchymosis, and swelling with instability. The goal of this study is to test the validity of a new clinical examination maneuver, the lateral drawer test, against the gravity stress view (GSV) in a cohort of patients with Weber B fibula fractures. Secondary goals included assessing pain tolerability of the lateral drawer test, as well as testing interobserver reliability. Methods: Sixty-two patients presenting with isolated fibula fractures were prospectively identified by an orthopaedic nurse practitioner or resident. Three nonweightbearing radiographic views of the ankle as well as a GSV were obtained. Radiographs were not visualized before conducting the lateral drawer test. Two foot and ankle fellowship–trained orthopaedic surgeons performed and graded the lateral drawer test. Radiographs were then examined and medial clear space (MCS) was measured. Visual analog scale (VAS) pain scores were obtained before and after testing. The results of the lateral drawer test were compared with radiographic measurements of MCS on GSV. A cadaveric experiment was devised to assess interobserver reliability of the lateral drawer test. Results: Thirty (48%) of 62 consecutively enrolled patients demonstrated radiographic instability with widening of the MCS ≥5 mm on GSV. When correlated with MCS measurement, the lateral drawer test demonstrated a sensitivity of 83%, specificity of 97%, positive predictive value (PPV) of 96%, and negative predictive value (NPV) of 86%. There was a strong correlation between the lateral drawer test grade and amount of MCS widening (Spearman correlation ρ = 0.82, P <.005). Patients tolerated the maneuver well with an average increase of 0.7 on the VAS pain scale. Testing of 2 observers utilizing the cadaveric model demonstrated a Cohen's Kappa coefficient of 0.7 indicating moderate interobserver agreement. Conclusion: The lateral drawer test demonstrates high sensitivity, specificity, PPV, and NPV with moderate interobserver reliability compared with the MCS on GSV in patients presenting with Weber B fibula fractures. Although further external validation is required, the lateral drawer test may offer an adjunct tool via physical examination to help determine mortise stability. Level of Evidence: Level II, Prospective Cohort Study. [ABSTRACT FROM AUTHOR]