Thursday, 3 July 2008

Quinke Sign in the Skin !!!!

Dear Bloggers

Sorry for keeping you waiting for new updates this week.

Here is a patient from with ankylosing spondylitis who was noticed to have pulsating carotid arteries in the neck.

Examination revealed a high upstroke volume of the radial pulse followed by a collapsing quality. The carotid pulsation was the classical Corrigan Sign.

Cardiac examination revealed a low grade systolic murmur at the aortic area with radiation to the carotid arteries in the neck. There was no audible diastolic murmur.

Femoral bruits were heard and the popliteal arteries were also palpable (in normal individuals it is unusual to feel the popliteal arteries unless hyperdynamic circulation or popliteal aneurysms are present).

As can be seen from the video below, Quinke Sign is strongly positive. Usually, one sees Quinke sign in the nail bed as a change in the redness that surrounds the white part of the nail near to the nail fold. It is a bit like watching the 'tide come in and out' in the nail. However, in this patient, the regurgitation was so strong, this change in blood flow pattern could be seen in the skin !!!

This patient had suspected Aortic Regurgitation. 

Ankylosing spondylitis is associated with aortic root dilatation and may precipitate aortic regurgitation. Other causes of aortic dilatation include:
  • Marfan's Syndrome
  • Reiter's Syndrome
  • Atherosclerosis
  • Syphilis (aortitis)
  • Hypertension
Causes of Aortic Regurgitation not associated with dilatation include:
  • Rheumatic heart disease
  • Infective Endocarditis
  • Trauma
  • Bicuspid valves
  • Disproportionate cusps
As a first year doctor in the UK, I first found Quinke sign in an elderly lady with accelerated hypertension who had a wide-pulse pressure. On the ward round the next morning I mentioned to the consultant that the patient had Quinke sign. The consultant boastfully said that he had never seen it-- until he indeed checked the patient and confirmed that it was indeed Quinke sign!!

Just because you may have not seen a sign does not mean that it does not exist anymore or is somehow obsolete. I have seen Quinke sign over a dozen times or more in my career by just spending the time to look for the sign when considering the diagnosis of Aortic Regurgitation.

Things to think about at the bedside to suspect the diagnosis include:

  1. Wide Pulse Pressure
  2. Collapsing pulse and Water Hammer pulse
  3. Quinke Sign
  4. Corrigan Sign 
  5. De Mussett's Sign (head nodding with the cardiac cycle)
  6. Femoral Bruits 'Pistol Shot'-type
  7. Popliteal pulses being palpable
  8. Aortic ejection systolic flow murmur
  9. Diastolic flow murmur
Have a good day!


video

Sunday, 29 June 2008

Headache and Sensory Changes - History Reveals All !!

Dear Bloggers

This next case has been anonymised for safeguarding patient confidentiality.

In a recent case at a distant hospital in Japan, a young patient was admitted with a headache and sensory changes down the left side of her body.

The headache had occurred in the morning and had woken the patient from sleep. She had severe pain and was unable to stand. She then noticed that she had sensory changes down the left side of her body although her limb movements appeared to be unimpaired. 

She mentioned to the junior resident that she had no previous medical history of note and was taking no regular medications.

There was no history of thrombotic diathesis, no symptoms of SLE, no pregnancy or consumption of oestrogens and no smoking history. She had no subjective fever and had no preceding infective symptoms. She complained of no neck stiffness or photophobia. She had not had any preceding sexual intercourse prior to the onset of symptoms (n.b. sexual intercourse is a classic history before SAH). There was  no chest pain or interscapular pain. She complained of no bone / vertebral pain and the headache was not worsened by subjective head or neck movement.

On examination (when seen by the resident), there were focal problems on general physical examination.

Neurological examination revealed left sided cerebellar signs of slowed irregular movement when performing finger-to-nose examination, mild nystagmus to the left side and dysarthria. There was sensory loss including modalities of light touch and nociception on the same side.
There was no sensory loss involving the face, and cranial nerves were otherwise normal.

The differential diagnoses before cranial imaging included:
  1. Stroke (infarction or bleed) causing a Wallenberg Syndrome (Lateral Medullary Infarction)
  2. Encephalitis
  3. Meningitis
  4. Transverse Myelitis
After several hours, the patient had had several studies including CSF examination and a cranial MRI scan.

The patient was then seen by a senior physician who wanted more history!!

The patient first mentioned the headache. The senior physician asked the patient to explain the quality of the pain. The patient replied that it was a throbbing type pain. Such throbbing is generally inconsistent with any of the above causes. 

The next question was whether the pain was unilateral or bilateral. The patient mentioned that it was predominantly unilateral.
The physician then asked if the patient had a 'history of migraines'. The patient said-- YES!
The next question was- 'Is this the same pain as with previous migraine attacks?' -- YES!

Why the patient had not mentioned migraine to the resident doctor is anyone's guess, but it is clear that the diagnosis of migraine had not be entertained because the quality of the headache had not initially been appreciated. Pain in the head is not simply pain. Pain has many different qualities e.g throbbing, lancinating, pressure-type, superficial, deep etc. However, in a young patient, throbbing pain would make one consider migraine whereas in an elderly patient, temporal arteritis might be the cause.

Some patients do not remember their medical history in detail and may have infrequent migraine episodes such that they do not think to mention it to the doctor. The fact that the patient had a headache should always make the physician consider whether migraine is a possible cause. 

Basilar-Type Migraine can cause headache and peripheral sensory problems such as this.

The patient recanted the previous migrainous episodes and there had always be a visual aura. However, on this occasion the patient had awoken with the symptoms and hence, no aura had occurred. However, migraines classically can occur upon waking and may even wake the patient from sleep!

On physical examination, the cerebellar signs were still mildly present but the sensory deficits had completely resolved which was not consistent with an infarction (unless it was TIA) , bleed or infective cause, but it was more consistent with basilar type migraine.

The MRI scan was normal as was the CSF examination.

The patient was given simple pain relief (acetaminophen) but not anti-migraine treatment, as in basilar-type migraine such abortive therapies can be associated with infarction and are best omitted. Symptoms entirely resolved and the patient was discharged home on the same day.

When asking about pain one needs to know several things which include:

  • Location
  • Quality
  • Severity
  • Onset (sudden or slow onset)
  • Causative, relieving or exacerbating factors
  • Radiation
  • Duration
  • Associated symptoms
There is a medical mnemonic to help with this as follows:

COLD RAP TAPE

C- Character e.g. What is it like?
O- Onset e.g. When did it start?
L- Location e.g. Where did you notice it?
D- Duration e.g. How long does it last?

R- Relieving factor e.g. What makes it better?
A- Aggravating factors e.g. What makes it worse?
P- Precipitating factors e.g. What brings it on?

T- Therapy e.g. What have you tried to make it better?
A- Associated symptoms e.g. Do you have any other symptoms along with this?
P- Past medical history e.g. Have you ever had anything like this before?
E- Emotional impact e.g. what concerns do you have about this and how it may affect your life

The work up of the patient by the resident was entirely correct to rule out severe pathologies and I fully support that approach. If the patient were to have further episodes of Basilar-Type Migraine, the patient should not have further investigations unless there are unusual features e.g. neck stiffness, fever, persistent symptoms i.e. failure to resolve, because such investigations are unlikely to be revealing.

For further reading on this neurological condition, please see UpToDate or any good medical text.

As for the actual diagnosis, this was reached within 4 questions by taking more history.

Please consider asking about migraine when you see a patient. Enquire about visual symptoms, cluster-type headaches, worsening of headaches with neck movement, laterality of pain, pain quality, severity, associated symptoms etc, as listed above. These features will help you discriminate the likely cause and guide you with further tests and therapeutics.

Please consider....