Ataxia: The Physical Examination

Ataxia is an extremely important clinical sign that has a broad and important differential diagnosis. Causes of ataxia include posterior circulation strokes and various toxic and metabolic insults to the cerebellum (and sometimes to the spinocerebellar tracts). Ataxia can be a very subtle physical finding, especially when you don’t know what to look for or when you are… Read More »

Purpura in Children

The differential diagnosis of purpura in children depends about two considerations: (1) Does the patient look ill? and (2) What is the platelet count? Here’s how it goes: Appearance Platelet Count Causes Sick Low Meningococcemia, Leukemia, DIC, Hemolytic-Uremic Syndrome (HUS) Sick Normal or High (*) Viremia (e.g., EBV), Vasculitis (e.g., Mucocutaneous lymph node syndrome [Kawasaki]) Well Low Immune Thrombocytopenic Purpura (ITP),… Read More »

Primary Pediatric Radiology

The formula for writing an exceptionally good radiology book is pretty straightforward: Well-organized chapters based on cardinal clinical scenarios Specific recommendations with regard to when and whom to image (or not to image!) Excellent images and annotations Primary Pediatric Radiology, by Susan Williamson, M.D., delivers on all of these points. It is a clinically oriented book, with chapters that are organized… Read More »

When to suspect an inherited metabolic disease

Here are seven cardinal clues to the presence of an inherited metabolic disease (“inborn error of metabolism”): Normal pregnancy and birth, but the infant begins to deteriorate after an asymptomatic interval (usually after the first 24 hours of life) Symptoms are precipitated or exacerbated by changes in metabolic state or dietary habits: feeding, starvation, dietary changes, or exertion. Progressively worsening dysmorphic… Read More »

How to Manage Somatic Symptom Disorder in Medical Settings

Introduction Somatic Symptom Disorder (previously known, roughly, as somatization disorder) is a maladaptive and counterproductive focus on physical symptoms or sensations, real or imagined. Patients with somatization disorders are really (and sometimes really, really!) suffering, it’s just that they have non-physical states and comorbidities that are making their symptoms worse. These include psychological determinants (e.g., anxiety, depression), social determinants (e.g., social isolation),… Read More »

The Clinical Significance of the Various Descriptions of Vomitus

Undigested food → esophageal issue (e.g., pharyngeal pouch or achalasia). Note: this is not really vomiting, but regurgitation, which is much less forceful and does not come from the stomach (and therefore not associated with nausea!) Non-bilious, with partially digested food → Gastric outlet obstruction (e.g., from peptic ulcer disease or malignancy, or from pyloric stenosis) Gastroparesis Bilious (green) →… Read More »

Physical Examination of Muscles in Systemic Disease

How to examine patients and report findings in patients with suspected muscle diseases: Abnormal movements Fasciculation → peripheral nerve injury Tremor Resting → Parkinsonism (with bradykinesia and rigidity) Intention → cerebellar issue → look for additional signs of cerebellar problems (e.g., ataxia) Myoclonus (involuntary purposeless jerks of limbs) → toxic metabolic issues (e.g., hypoxia, uremia, serotonin syndrome, opioid… Read More »